Fall Prevention Strategies

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Fall Prevention StrategiesEvidence-Based Tools to Reduce Re-Hospitalization and Maximize Functional Outcomes

Presented by Brandi Singleton, PT, DPT, CCI

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Fall Prevention StrategiesEvidence-Based Tools to Reduce Re-Hospitalization and Maximize Functional Outcomes

Brandi Singleton

ѩ 1. Identify three physiological contributors to falls in the elderly population.

ѩ 2. Utilize appropriate assessment tools for determining fall risk in the aging senior population.

ѩ 3. Implement treatment of balance deficits to prevent hospital re-admissions with or without cutting-edge equipment.

ѩ 4. Develop individualized exercise programs to improve strength and stability in older adults with balance deficits.

ѩ 5. Conduct environmental modifications on a shoestring budget to prevent falls in the home.

ѩ 6. Justify medical necessity and ensure reimbursement with accurate documentation of balance and strength training services.

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Workshop Notes

Workshop Notes

Workshop Notes

Fall�Prevention�Strategies

Evidence�Based�Tools�to�Reduce�Re�Hospitalizationand�Maximize�Functional�Outcomes

Presented�by:Brandi�Singleton,�PT,�DPT,CCI

1

Course�Objectives1. Understand�the�Impact�that�Falls�Have�on�the�

Healthcare�Industry2. Identify�Various�Contributors�to�Falls�in�the�

Geriatric�Population3. Administer�The�Best�Standardized�Assessment�

Tools�to�Track�Patient�Functional�Status4. Provide�Customized�Treatments�for�Patients�of�

Varying�Functional�Levels5. Teach�Essential�Skills�Needed�to�Reintegrate�Into�

Home�and�Community�Environments6. Master�Effective�and�Efficient�Documentation�

Based�on�the�Latest�Medicare�Guidelines.�2

What�impact�do�falls�have�on�the�healthcare�industry�as�a�whole?

3

Impact�of�Falls

• Each�year�~30%�of�adults�over�the�age�of�65�experience�a�fall

•20%�of�falls�result�in�serious�injury�requiring�visits�to�the�emergency�room

•40%�of�hospital�admissions�of�older�adults�are�a�result�of�falls

4

Impact�of�falls

• Falls�are�the�leading�cause�of�death�from�injury�in�older�adults

• Even�without�injury,�falls�often�lead�to�a�downward�spiral,�resulting�in�inactivity,�decreased�strength,�balance�problems,�and�decreased�independence

• $30�million�is�spent�annually�in�direct�and�indirect�medical�costs�related�to�falls

5

Role�of�Therapists�in�Falls�Prevention

• Evidence�suggests�that�falls�can�be�prevented�by:

• Screening�to�determine�risk�factors�

• Prescription�of�individualized�interventions�to�address�risk�factors

6

11

Identifying�and�understanding�risk�factors�for�falls�in�the�aging�senior�

population• Intrinsic�risk�factors

• Extrinsic�risk�factors

•Psychological�risk�factors

•Vestibular�Influences�on�balance�deficits7

Intrinsic�Risk�factors

• Visual�deficits

• Impaired�sensation

•Medication�side�effects

• Incontinence

• Proprioceptive�deficits

•Muscle�weakness

• Gait�impairments

• Neurological�deficits

8

Visual�Deficits

•Age�related�visual�changes• The�ability�of�the�eyes�to�adjust�to�change�in�lighting�diminishes�with�age�– more�time�required�to�adjust,�especially�with�transition�to�dark.

• Reduced�contrast�sensitivity�limits�perception�of�objects�in�environment

• Deficits�in�depth�perception� 9

Visual�Deficits

•Conditions�commonly�seen�in�the�aging�population:• Cataracts

• Glaucoma�

•Macular�degeneration

• Neurologic�Vision�Impairments10

Cataracts

• Eye�lens�progressively�becomes�more�opaque

•Presents�as�“cloudy”�or�”blurred�vision

•Can�be�effectively�treated�with�surgical�procedure

11

Glaucoma

• Caused�by�damage�to�the�optic�nerve

• Peripheral�vision�is�lost�first

•With�progression�medial�vision�also�lost�–presents�like�“tunnel�vision”

• There�is�no�cure�for�glaucoma�and�visual�losses�are�permanent 12

12

Macular�Degeneration• Damage�to�central�part�of�the�retina�(the�macula)• Early,�intermediate,�and�late�stages• Symptoms�typically�not�reported�until�late�stages

• Leads�to�”low�vision”• Difficulty�reading• Difficulty�recognizing�objects�and�facial�features

• Central�vision�is�completely�lost�in�advanced�stages�– legally�blind• Peripheral�vision�is�often�retained

13

Neurologic�Vision�Impairments

•Visual�field�cuts

•Visual�field�neglect

14

Left�homonymous�hemianopsia

Normal�view

15Drawing�tests�of�a�patient�with�left�visual�neglect 16

Sensory�Impairments

• Sensory�impairments�play�a�large�role�in�falls�in�the�geriatric�population

•People�with�diabetic�peripheral�neuropathy�have�a�larger�sway�in�anterior�posterior�and�medial�lateral�directions�and�a�higher�sway�speed�compared�with�other�individuals�in�the�same�age�group

17

Sensory�Impairments

•Postural�sway�is�even�greater�in�individuals�with�diabetic�peripheral�neuropathy�when�eyes�are�closed�–visual�compensation

•Compensation�is�very�important�for�this�population!

18

13

Double�Trouble!• Patients�who’s�sensory�deficits�are�related�to�diabetic�peripheral�neuropathy�(DPN)�often�also�have�visual�deficits�from�the�condition,�known�as�diabetic�retinopathy

• Now�the�individual�is�further�compromised�and�at�a�higher�risk�for�falls

• Proper�assistive�device�selection�is�very�important�when�this�set�of�symptoms�is�present*

19

Medication�Side�Effects

• Incidence�in�falls�increases�in�individuals�who�utilize:• Psychotropic�drugs

• Cardiac�drugs

• Polypharmacy• Use�of�two�or�more�drugs�concurrently�

20

Common�Psychotropic�Drugs

• Benzodiazepines• Diazepam�(Valium),�Lorazepam�(Ativan),�Clonazepam�(Clonipin)

• Anti�depressants• Sertraline�(Zoloft),�Fluoxetine��(Prozac),�Escitalopram�(Lexapro),�Citalopram�(Celexa)

• Antipsychotics�• Risperdone (Risperidol),�Haloperidol�(Haldol),�Olanzapine�(Zyprexa)

21

Common�Cardiac�Drugs

• Beta�Blockers• Atenolol�(Tenormin),�Metoprolol�(Lopressor)

• Calcium�Channel�Blockers• Amlodipine�(Norvasc),�Diltiazem�(Cardizem)

• Diuretics• Furosemide�(Lasix),�Bumetadine (Bumex),�Chlorothiazide (Diuril)

22

Quick�Resource�for�Drug�Information�and�Side�Effects

23

Proprioceptive�Deficits

•When�surfaces�are�varied�and�vision�is�controlled�for,�low�stance�duration�is�related�to�postural�control�beginning�at�the�ankle

• Somatosensory�input�from�the�ankles�provides�a�critical�source�of�information�for�controlling�the�degree�in�body�sway�in�elders�who�fall

24

14


•We�can�improve�proprioception�by�challenging�our�patients’�balance�in�the�clinic

• Strengthen�righting�and�reaction�strategies�by�eliciting�them

25

Incontinence

• Incidence�of�falls�increased�in�patients�with�urge�incontinence�and�stress�incontinence

• Urge�incontinence�• The�sudden�urge�to�urinate�with�little�to�no�warning

• Stress�incontinence• Involuntary�loss�of�urine�when�abdominal�pressure�increases• Can�be�triggered�by�coughing,�sneezing,�laughing,�jumping,�etc.�

26

Incontinence�

•May�lead�to�reduction�in�mobility�due�to�patient’s�preoccupation�with�remaining�close�to�a�restroom

• Patients�with�these�types�of�incontinence�may�not�be�aware�of�environmental�hazards�due�to�anxiety�related�to�incontinent�episodes

27

How�can�we�help�reduce�the�incidence�of�falls�related�to�

incontinence?•Reducing�extrinsic�factors�such�as�clutter

•Recommending�DME�to�improve�safety

•Pelvic�floor�therapy

•Bowel�and�bladder�program�training�and�implementation 28

Extrinsic�Risk�Factors

29


30

15


31

Extrinsic�Risk�Factors�Special�Consideration:�Diabetic�Footwear

32

Extrinsic�Risk�Factors�Special�Consideration:�Diabetic�Footwear

• Footwear�is�particularly�important�to�the�diabetic�patient

•We�must�stress�this�importance�if�we�notice�a�patient�with�diabetes�not�wearing�appropriate�footwear

• Educate�patient�regarding�foot�hygiene�and�daily�skin�checks

33

Extrinsic�Risk�Factors�Special�Consideration:�Diabetic�Footwear• Inform�patient�that�with�a�diagnosis�of�diabetes,�Medicare�will�cover�one�pair�of�diabetic�shoes,�including�custom�shoes�per�calendar�year

•Medicare�will�also�cover�two�pairs�of�custom�inserts�per�calendar�year

•We�must�stress�the�importance�of�proper�footwear�for�the�diabetic�patient�both�to�aid�in�fall�prevention�and�in�overall�patient�well�being

34

Psychological�Risk�Factors

•Cognitive�deficits

• Fear�of�falling

35

What�role�do�cognitive�deficits�play�in�fall�risk?• Impaired�executive�function• Planning• Execution• Initiation• Judgement• Safety�awareness• Diminished�ability�to�perform�complex�tasks

36

16

Dementia

• A�set�of�symptoms�that�can�include�memory�loss,�difficulty�thinking,�impaired�problem�solving,�or�language�deficits

•We�will�see�various�causes�of�Dementia,�including:• Alzheimer’s�Disease

• Vascular�Dementia

• Lewy�Body�Dementia�

37

Alzheimer’s�Disease

•Most�common�type�of�dementia

• Initial�symptoms�include�short�term�memory�loss

• Disorientation�

• Impaired�Judgement

• Downward�gaze�and�shuffling�gait38

Vascular�Dementia

•Multi�infarct�or�post�stroke�dementia

• Initial�symptoms�include�impaired�judgement�and�difficulty�with�sequencing�tasks

• Symptoms�related�to�region�of�the�brain�that�is�affected�by�vessel�blockages

39

Lewy�Body�Dementia

• Caused�by�clumps�of�proteins�in�the�brain�(Lewy�Bodies)

•More�likely�to�have�earlier�onset�of�hallucinations,�gait�disturbances,�reduced�gait�speed�and�other�Parkinsonian�movement�deficits

40

Mixed�Dementia

• The�presence�of�two�or�more�types�of�dementia

41

Stages�of�Dementia�and�how�they�affect�fall�risk�and�our�ability�to�improve�patient�

outcomes• Stage�1: Normal�– Independent• Stage�2:�Mild�memory�loss�� Independent• Normal�on�tests

• Stage�3:�Mild�cognitive�impairment�– Independent/Part�time�assistance• Deficits�may�be�noticeable�to�those�who�know�individual�well• Possible�objective�deficits�on�testing

• Stage�4: Early�Dementia�– Independent/Assist�from�caregivers�or�family• Difficulty�with�complex�tasks• Denial�or�withdrawal�may�be�present• Deficits�on�testing

42

17

Stages�of�Dementia�and�how�they�affect�fall�risk�and�our�ability�to�

improve�patient�outcomes�continued• Stage�5:Moderate�Dementia�– Full�time�supervision�assistance• Forgetful�– may�forget�family�members• Disorientation• Difficulty�choosing�appropriate�clothing• Can�perform�ADLs�without�assistance

• Stage�6:Moderately�Severe�Dementia�– Complex�care�facility• May�forget�name�of�close�family�members• Unaware�of�life�events• Assistance�with�ADLs• Psych�symptoms�common�(i.e.�agitation,�delusions)

43

Stages�of�Dementia�and�how�they�affect�fall�risk�and�our�ability�to�

improve�patient�outcomes�continued• Stage�7: Severe�Dementia• Verbal�abilities�lost• Unable�to�ambulate• Unable�to�feed�self

44

Brain�Injury

• Visual�perceptual�impairments

• Difficulty�sustaining�movements

• Impulsive�behavioral�style

• Decreased�awareness�of�impairments

• Poor�judgement

• Difficulty�with�self�correction

• Difficulty�processing�visual�cues

• Memory�impairments

Right�brain�injury�often�leads�to:

45

Brain�Injury

• Difficulty�with�planning�and�sequencing�movements

• Apraxia

• Disorganized�problem�solving

• Processing�delays

• Difficulty�processing�verbal�cues�or�commands

Left�brain�injury�often�leads�to:

46

What�is�fear�of�falling?

• Defined�as�an�ongoing�concern�about�falling�that�limits�the�performance�of�daily�activities

• Present�in�12%�65%�of�community�dwelling�adults�over�65�who�have�not fallen

• Present�in�29%�92%�of�adults�over�65�who�have�experienced�a�fall

47

Why�are�we�concerned�with�fear�of�falling?

• Often�presents�as�patient�not�wanting�to�participate�in�an�activity�that�they�once�enjoyed�or�cared�about

• Correlated�with�decreased�quality�of�life

• Indicator�of�increased�morbidity�and�mortality

• Results�in�further�decline�in�functional�status48

18

Identifying�Vestibular�Influences�on�Balance�

Deficits

49

Three�Systems�Assist�With�Maintenance�of�Balance

•Vision

•Proprioception

•Vestibular�Inputs

50

The�Vestibular�System

51

Vestibular�Dysfunction

• Symptoms:• Dizziness• Nausea• Vomiting• Subjective�report• “getting�dizzy�when�turning�in�bed”�• “getting�dizzy�when�turning�head�quickly”

• Rapid�eye�movements�(nystagmus)

52

Vestibular�dysfunction

•Vestibular�influences�must�be�identified�or�ruled�out�before�we�proceed�to�utilize�strengthening�and�balance�interventions�for�an�individual

•Most�common�form�is�benign�paroxysmal�positional�vertigo�(BPPV)

53

Vestibular�Dysfunction•Differentiate�peripheral�vs.�central�lesions�causing�vestibular�symptoms

• If�peripheral�symptoms�are�found�further�vestibular�evaluation�is�indicated

•Central�symptoms�require�referral�for�further�assessment

54

19

Central�Vestibular�Red�Flags��• Severe�ataxia

• Abnormal�smooth�pursuit

• Brainstem�symptoms• i.e.�diplopia,�dysarthria,�altered�consciousness

• Pendular nystagmus�(eyes�oscillate�at�equal�speeds�– no�slow�or�fast�phase)

• Persistent�vertical�nystagmus�that�persists�without�positional�testing

55

Assessment�tools�for�Balance�Dysfunction

56

Utilizing�appropriate�assessment�tools�for�determining�fall�risk�in�the�

aging�senior�population•Physical�based�assessments

•Psychological�based�assessments

57

Physical�based�Assessments

• BERG�Balance�assessment

• Tinetti Performance�Oriented�Mobility�Assessment�(POMA)

• Four�Step�Square�Test

• Timed�Up�and�Go�(TUG)�Test

• Dynamic�Gait�Index�(DGI)

• Functional�Reach�Test

• Five�Times�Sit�to�Stand�(FTSS)�Test

• Walking�Speed�Assessment�

58

BERG�Balance�Assessment�

•Objective�assessment�to�assess�static�balance�and�fall�risk

• Instructions:�Lead�patient�through�14�item�assessment• Includes:�sit�<�>�stand,�transfers,�static�standing,�EC,�forward�reach,�head�turns,�360�degree�turns,�alternating�step�tapping,�narrow�BOS�standing,�tandem�standing,�SLS,�object�retrieval�from�floor

59

BERG�Balance�Assessment

• Total�points:�56

•Categories:• 0�20:�high�fall�risk/wheelchair�bound• 21�40:�medium�fall�risk/walks�with�assistance�or�assistive�device• 41�56:�low�fall�risk• 46�and�above�indicate�lowest�fall�risk*

60

20

Tinetti Performance�Oriented�Mobility�Assessment�(POMA)

•Objective�measure�of�balance�and�gait�abilities

• Instructions:�lead�patient�through�16�item�assessment• Includes:�sitting�balance,�sit�<�>�stand,�standing�balance,�perturbation,�romberg,�360�degree�turns,�gait�initiation,�gait�quality,�trunk�sway�during�gait,�walking�stance

61

Tinetti Performance�Oriented�Mobility�Assessment�(POMA)

• Total�points:�28• 16�Balance• 12�Gait

•Categories:• High�fall�risk:�<19•Medium�fall�risk:�19�24• Low�Fall�risk:��25�28

62

Four�Step�Square�Test

• Objective�timed�test�that�measures�dynamic�values�in�various�directions• Instructions

• 4�canes�(or�other�raised�objects)�placed�on�floor�to�make�squares

• Patient�instructed�to�complete�the�sequence�shown�as�quickly�as�possible�without�touching�the�canes

• Stopwatch�begins�when�foot�contacts�square�2�and�stops�when�last�foot�touches�floor�in�square�1 63

Four�Step�Square�Test

•Best�of�two�times�is�score�used

•Categories/cutoff:�• >15�seconds�indicates�at�risk�for�multiple�falls

64

Timed�Up�and�Go�(TUG)�Test• Objective�timed�test�of�balance�and�functional�abilities

• Instructions:• Patient�begins�test�seated�in�a�standard�armchair• Walking�aides�may�be�used• When�instructor�says�“go”�patient�walks�to�a�line�3�meters�(9.8�feet)�away,�turns�around�and�walks�back�to�chair,�and�sits�down

• Test�ends�when�patient’s�buttocks�hit�the�seat• Patient�is�instructed�to�walk�at�a�comfortable�walking�speed

• A�stopwatch�is�used�to�time�the�test – an�average�of�3�trials�determines�score

65

Timed�Up�and�Go�(TUG)�Test

•Categories:• Times�>�14�seconds�indicate�high�fall�risk• Times�<�20�indicate�that�an�individual�is�able�to�ambulate�without�assistance• Times�>30�indicate�an�individual�who�requires�assistance�for�functional�mobility�tasks

66

21

Dynamic�Gait�Index

• 8�item�objective�test�utilized�to�assess�a�patient’s�ability�to�modify�balance�while�ambulating�in�the�presence�of�external�demands

• Includes:�Gait�on�level�surfaces,�change�in�gait�speed,�gait�with�horizontal�head�turns,�gait�with�vertical�head�turns,�gait�with�pivot�turns,�stepping�over�obstacles,�walking�around�obstacles,�steps�(stairs)

67

Dynamic�Gait�Index


•Categories:�• <19/24:�predictive�of�falls�in�the�elderly• >22/24:�safe�ambulators

68

Functional�Reach

• Objective�measure�of�patient’s�ability�to�reach�forward�• Instructions• Yardstick�mounted�to�wall�at�level�of�patient’s�acromion�in�standing

• Patient�stands�close�to�wall�with�arm�in�90�degrees�of�shoulder�flexion�with�closed�fist

• Starting�position�recorded�at�3rd metacarpal�head�on�yardstick

• Patient�instructed�to�reach�as�far�as�they�can�without�taking�a�step

• Difference�between�start�and�end�position�measured�(usually�in�inches)

• 5�trials�allowed:�2�practice�and�then�average�of�3�test�trials

69

Modified�Functional�Reach• Instructions:• Yardstick�mounted�to�wall�at�level�of�patient’s�acromion�in�sitting• Hips,�knees,�ankles�positioned�at�90�degrees�flexion�with�feet�on�floor• Starting�position�measured�as�position�of�third�metacarpal�head�with�patient�sitting�against�back�of�chair�with�UE�flexed�to�90�degrees• Measurements�taken�in�3�positions:• Sitting�with�UE�near�wall�leaning�forward• Sitting�with�back�to�the�wall�leaning�right• Sitting�with�back�to�the�wall�leaning�left

70

Modified�Functional�Reach

• Instructions�(cont.):�• Patient�instructed�to�lean�as�far�in�each�direction�as�possible�without�rotation�and�without�touching�wall• Once�patient�leans,�mark�position�of�3rd metacarpal�head�along�yard�stick• If�patient�unable�to�make�a�fist�use�ulnar�styloid�process�as�landmark• Record�distance�(usually�in�centimeters)�covered�in�each�direction• If�patient�unable�to�raise�affected�arm�use�distance�covered�by�acromion�in�leaning• First�trial�is�practice�and�not�recorded�in�final�measurement

71

Functional�Reach�&�Modified�Functional�Reach�Test

•Categories• Community�dwelling�seniors• <�7�inches�(17.78�cm)�indicates:�unable�to�leave�neighborhood�without�help,�limited�mobility�skills,�and�most�restricted�in�ADL

• Frail�seniors• <�7.3�inches�(18.5�cm)�indicates�fall�risk

72

22

Five�Times�Sit�to�Stand�(FTSS)�Test

• Objective�assessment�of�functional�lower�extremity�strength,�transitional�movements,�balance,�and�fall�risk

• Instructions:• Patient�seated�upright��with�arms�folded�and�back�against�chair�in�standard�height�chair�with�straight�back• Patient�instructions:�“please�stand�up�straight�as�quickly�as�you�can�five�times,�without�stopping�in�between.��Keep�your�arms�folded�across�you�chest,�ready�begin”

73

Five�Times�Sit�to�Stand�(FTSS)Test�

• Timer�started�when�therapist�says�“begin”�and�stopped�when�patient�reaches�standing�position�on�fifth�repetition�

•Categories:• >�13.6�seconds�associated�with�increased�disability�and�morbidity• >�15�seconds�predictive�of�recurrent�falls

74

Walking�Speed

•Objective�measurement�of�gait�speed�measure�by�patient�walking�a�known�distance�with�the�distance�and�time�converted�into�m/s

• Implications•Walking�speed�<1.0�m/s�is�indicative�of�increased�falls,�increased�morbidity,�and�increased�mortality�in�the�aging�senior�population

75

Walking�Speed�Assessments

• 10�meter�walking�test�(20�meter�course)• Found�to�have�similar�implications�to�2�minute�walk�test�and�takes�less�time�in�the�clinic• Speed�is�measured�in�the�central�10�meters�of�a�20�meter�course

• 4�meter�walking�test�(6�meter�course)• Useful�in�small�environments�such�as�home/small�clinics• Speed�is�measured�in�central�4�meters�of�6�meter�course

76

Psychological�based�Assessments

• Tinetti Falls�Efficacy�Scale�(FES)

•Activities�specific�Balance�Confidence�Scale�(ABC)

77

Tinetti Falls�Efficacy�Scale�(FES)

• 10�item�subjective�test�to�assess�balance�and�stability�during�activities�of�daily�living�and�fear�of�falling�in�the�elderly�population

• Instructions�read:�”how�confident�are�you�that�you�do�the�following�activities�without�falling…”• taking�bath/shower,�reaching�into�cabinets/closets,�walking�around�house,�preparing�meals,�answering�door/phone,�getting�in/out�of�chair,�enter/exit�car,�dressing/undressing,�personal�grooming,�getting�on/off�toilet

78

23

Tinetti Falls�Efficacy�Scale�(FES)

•Answers�range�from�1(very�confident)�to�10�(not�confident�at�all)


•Categories:• Scores�>�70�indicative�of�fear�of�falling�in�the�elderly

79

Activities�specific�Balance�Confidence�(ABC)�Scale

• 16�item�subjective�measure�of�confidence�in�performing�various�ambulatory�activities�without�falling�or�experiencing�a�sense�of�unsteadiness

• Instructions�read:�“how�confident�are�you�that�you�will�not�lose�your�balance�or�become�unsteady�when�you…”• Walk�around�house,�walk�up/down�stairs,�bend�to�pick�up�slipper,�reach�for�eye�level�shelf,�stand�on�tip�toes�and�reach�overhead,�stand�on�chair�and�reach,�sweep�floor,�walk�to�car�in�driveway,�get�in/out�of�car,�walk�across�mall�parking�lot,�walk�up/down�ramp,�walk�in�crowded�mall,�step�on/off�escalator�holding�railing/not�holding�railing,�walk�on�icy�sidewalks 80

Activities�specific�Balance�Confidence�(ABC)�Scale

• Patient�gives�percentage�ratings�0%�(no�confidence)�to�100%�(completely�confident)�to�each�question�then�total�is�divided�by�16�to�get�percentage

• Categories:• >80%:�high�level�of�physical�functioning• 50�80%:�moderate�level�of�physical�functioning�• <50%:�low�level�of�physical�functioning• <67%:�older�adults�at�risk�for�falling;�predictive�of�future�fall

81

Quick�Reference�for�Standardized�Test�and�Measures

www.rehabmeasures.org

82

Evaluation�Considerations�when�assessing�the�high�fall�risk�

population

83

Chart�Review

• PMH/PSH

• Co�morbidities�

•Medications

• Precautions

• Contraindications84

24

Subjective

• Prior�level�of�function

•Who�lives�in�home�with�patient?

•Was�an�assistive�device�used?

• Are�there�steps�into�or�inside�of�home?

85

Subjective

•What�is�the�set�up�of�the�restroom?

•Was�patient�managing�medicines?• What�strategies�were�used?

•Was�patient�driving?

•Who�did�grocery�shopping?

86

Subjective•Was�patient�cooking?• If�so,�light�meal�prep�or�heavy�meals?

•Was�patient�doing�own�laundry?• At�home�or�laundromat?

•Was�patient�managing�finances?

•What�type�of�family�and�social�support�does�patient�have?

87

Subjective

•What�are�the�patient’s�goals

• Caregiver/family�goals?

• Hobbies?

• Occupation?• Current�or�past

88

Subjective• Falls�history

• Psychological�based�standardized�assessments

• Level�of�alertness

• Orientation

• Safety�awareness89

Subjective

• Discharge�plan�–*discharge�planning�begins�on�evaluation�day*

• Is�plan�to�return�to�prior�living�setting?• If�not,�what�is�the�plan?

•What�DME�does�patient�already�own?• This�is�often�different�from�what�they�are�using

90

25

Objective

• Bathing�

• Dressing

• Toileting

• Grooming

91

Objective�

• Activity�tolerance

• Decision�making

• Ability�to�follow�commands�and�type�of�commands�required

• Current�assistive�device�needs

92

Objective�

• Standardized�Assessments

• Bed�mobility

• Transfers

• Balance�grade

• Range�of�motion93

Objective�

•Manual�Muscle�Testing• Key�muscles�for�the�high�fall�risk�patient:• Hip�flexors• Hip�abductors• Hip�extensors• Ankle�dorsiflexors• Shoulder�flexors• Elbow�extensors

94

Customized�Treatment�for�

Patients�of�Varying�Functional�Levels

95

What�Postural�abnormalities�does�your�client�have�that�may�affect�stability?

Sway�Back Lumbar�Lordosis

Thoracic�Kyphosis

Forward�Head

Good�Posture 96

26

Obj

ectiv

e: B

alan

ce G

radi

ng R

evie

w

Stat

ic S

ittin

g N

orm

al A

ble

to m

aint

ain

bala

nce

agai

nst m

axim

al re

sist

ance

Goo

d Ab

le to

mai

ntai

n ba

lanc

e ag

ains

t mod

erat

e re

sista

nce

G-/

F+

Acce

pts m

inim

al re

sista

nce

Fair

Able

to si

t uns

uppo

rted

with

out

bala

nce

loss

and

with

out U

E su

ppor

t

Poor

+ Ab

le to

mai

ntai

n w

ith m

inim

al

assis

tanc

e fro

m in

divi

dual

or

chai

r

Poor

Un

able

to m

aint

ain

bala

nce –

requ

ires m

od/m

ax su

ppor

t fro

m in

divi

dual

or c

hair

Dyna

mic

Sitt

ing

Nor

mal

Abl

e to

sit u

nsup

port

ed &

wei

ght s

hift

ac

ross

mid

line

max

imal

ly

Goo

d Ab

le to

sit u

nsup

port

ed &

wei

ght s

hift

ac

ross

mid

line

mod

erat

ely

G-/

F+

Able

to si

t uns

uppo

rted

and

wei

ght

shift

acr

oss m

idlin

e m

inim

ally

Fair

Min

imal

wei

ght s

hift

ing

ipsi

late

ral/f

ront

, diff

icul

ty c

ross

ing

mid

line

Fair-

Re

ach

to ip

sila

tera

l sid

e an

d un

able

to

wei

ght s

hift

Poor

+ Ab

le to

sit u

nsup

port

ed w

ith m

in A

and

re

ach

to ip

sila

tera

l sid

e, u

nabl

e to

w

eigh

t shi

ft Po

or

Able

to si

t uns

uppo

rted

with

Mod

A

and

reac

h ip

sila

tera

l/fro

nt – c

an’t

cros

s m

idlin

e

27

Obj

ectiv

e: B

alan

ce G

radi

ng R

evie

w

Stat

ic S

tand

ing

Nor

mal

Abl

e to

mai

ntai

n st

andi

ng b

alan

ce

agai

nst m

axim

al re

sist

ance

Goo

d

Able

to m

aint

ain

stan

ding

bal

ance

ag

ains

t mod

erat

e re

sista

nce

G-/

F+

Able

to m

aint

ain

stan

ding

bal

ance

ag

ains

t min

imal

resis

tanc

e

Fair

Able

to st

and

unsu

ppor

ted

with

out

UE

supp

ort a

nd w

ithou

t LO

B fo

r 1-

2 m

in

Fair-

Re

quire

s Min

A o

r UE

supp

ort i

n or

der t

o st

and

with

out L

OB

Poor

+ Re

quire

s Mod

A a

nd U

E su

ppor

t to

mai

ntai

n st

andi

ng w

ithou

t bal

ance

lo

ss

Poor

Re

quire

s Max

A a

nd U

E su

ppor

t to

mai

ntai

n st

andi

ng b

alan

ce w

ithou

t lo

ss

Dyna

mic

Sta

ndin

g

Nor

mal

Sta

nd in

depe

nden

tly u

nsup

port

ed,

able

to w

eigh

t shi

ft a

nd cr

oss

mid

line

max

imal

ly

Goo

d St

and

inde

pend

ently

uns

uppo

rted

, ab

le to

wei

ght s

hift

and

cro

ss

mid

line

mod

erat

ely

G-/

F+

Stan

d in

depe

nden

tly u

nsup

port

ed,

able

to w

eigh

t shi

ft a

cros

s mid

line

min

imal

ly

Fair

Stan

d in

depe

nden

tly u

nsup

port

ed,

wei

ght s

hift

, and

reac

h ip

sila

tera

lly,

LOB

whe

n cr

ossin

g m

idlin

e

Poor

+ Ab

le to

stan

d w

ith M

in A

and

reac

h ip

sila

tera

lly, u

nabl

e to

wei

ght s

hift

Poor

Ab

le to

stan

d w

ith M

od A

and

m

inim

ally

reac

h ip

sila

tera

lly, u

nabl

e to

cro

ss m

idlin

e

28

Mov

emen

t Fu

nctio

nal R

ange

of M

otio

n M

easu

rem

ent (

in

degr

ees)

N

orm

al R

ange

of M

otio

n M

easu

rem

ent (

in d

egre

es)

Hip

flex

ion

Gait

on le

vel s

urfa

ces:

30

Asce

ndin

g st

airs

: 47-

66

Desc

endi

ng st

airs

: 45

Sitt

ing

in a

vera

ge ch

air:

112

Squa

ttin

g: 1

15

Don

ning

sock

s: 1

20

120

Knee

flex

ion

Gait

on le

vel s

urfa

ces:

63

Asce

nd st

airs

: 93-

105

Desc

end

stai

rs: 8

7-10

7 Ri

se fr

om ch

air:

90

Sit i

n ch

air:

93

Tie

shoe

s: 1

06

Lift

obj

ect f

rom

floo

r: 11

7

135

Ankl

e do

rsifl

exio

n Ga

it on

leve

l sur

face

s: 1

0 As

cend

ing

stai

rs: 1

4-27

De

scen

ding

stai

rs: 2

1-36

20 (

from

neu

tral

)

Ankl

e pl

anta

rfle

xion

Ga

it on

leve

l sur

face

s: 1

5 As

cend

ing

stai

rs: 2

5-30

De

scen

ding

stai

rs: 2

4-31

50 (f

rom

neu

tral

)

Shou

lder

flex

ion

Reac

hing

into

hig

h sh

elf:

148

180

29

Swayback�posture

• Swayback�

• Posteriorly�positioned�shoulders

• Backward�lean�of�trunk

• Slight�flexion�of�knees

• Posteriorly�tilted�pelvis�97

Swayback�posture• Treatment�strategies:•Wall�standing• Promotes�postural�re�training• Patient�has�no�option�but�to�stand�in�improved�mildine position

• Promote�neutral�pelvic�position• Moving�patient�out�of�posterior�pelvic�tilt• Core�strengthening�• Quadriceps�strengthening�• Hamstring�stretching

98

Forward�head�posture

•Results�from�weakness�of�the�deep�anterior�neck�muscles

•Often�accompanied�by�shortened�upper�trapezius�and�levator scapulae�muscles�

99

Forward�head�posture• Treatment�strategies

• Stretching

• Strengthening

• Trigger�point�therapy

• Assess�for�trigger�points

• Presence�of�trigger�points�may�be�a�cause�for�

postural�compensation100

Chin�Tuck

TherabandResisted�Chin�Tuck

Upper�Trapezius�Stretch

Levator Scapulae�Stretch

101

Kyphotic�Posture

• Indicated�by�rounding�of�shoulders

• Sometimes�accompanied�by�thoracic�“hump”•May�be�fixed�or�flexible�deformity�

102

30

Kyphotic�Posture

• Treatment�strategies• Flexibility�exercises:• pectoralis�major�and�minor

• Strengthening�exercises• Rhomboids• Middle�trapezius

• Tactile�input• backpack

103

Corner�pec�stretch

Supine�bolster�pec�stretch

Tactile�input�using�backpack

Before After

104

Scapular�retraction

105

Stabilization�Exercises

•Don’t�forget�the�core!

•Core�stability�plays�a�huge�role�in�posture,�endurance,�and�overall�functional�mobility

106


• Core�stability• Beyond�the�rectus�– targeting�the�entire�core

• Utilize�body�position�as�a�tool�to�engage�more�structures�during�exercise

• Progressing�stabilization�exercises�as�the�individual�progresses

107 Quadruped�Alternating�Arm�&�Leg

Great�way�to�activate�multifidi

full�core�activation

Great�functional�carryover

UE�&�LE�joint�approximation

Coordination�&�postural�control

Hamstring�&�quadriceps�co�contraction

Glute�activation

108

31

Stabilization�exercises• Total�body�stability�training�

•We�must�make�our�patients�uncomfortable�in�the�clinic�to�make�them�comfortable�in�their�environment

•Having�good�balance�is�the�art�of�constantly�losing�your�balance�and�regaining�it�before�anyone,�including�you,�notices�– a�delicate�dance 109

Teach�Patients�How�To�Engage�Their�Innate�Motor�Responses�to�Balance�

Perturbation

110


•Awaken�a�patient’s�reaction�responses�by�changing�surfaces• Stability�ball/Theraball

• BOSU

• Foam�mat/Balance�pad

•Wobble�board111

How�do�we�affectively�challenge�the�high�level�patient?

• Add�resistance• i.e.�Resisted�walking

• Increase�difficulty�of�surfaces

• Evoke�activation�of�multiple�balance�strategies

• Randomize�activities• Speed,�direction,�obstacles

112

Resisted�walking

Great�way�to�challenge�dynamic�balance

Great�for�improving�endurance�

Resistance�increases�core�

activation

Increased�lower�

extremity�stability

113

Romberg Sharpened/Tandem�RombergGreat�way�to�identify�deficits

Great�way�to�activate�postural�strategies

Identify�compensatory�strategies�&�strengthen�weak�areas 114

32

BOSU�Lunges:�Modified�forward�lunge BOSU�Lunges:�Full�forward�lunge

Great�way�to�

strengthen�ankle�&�stepping�strategies

Activation�of�

multiple�muscle�groups

Dynamic�stability�training

115

BOSU�forward�step�through

Stepping�strategies

Reaction�strategies

Ankle�stability

Hip�stability Postural�

awareness

116

BOSU�unilateral�step�reaching BOSU�standing�with�reaching

Total�body�stability�with�

functional�task

Challenge�limits�of�stability

117BOSU�barefoot�standing BOSU�side�step

Lateral�stability

Improve�activation�of�foot�intrinsics

118

Resisted�side�stepping�with�squat

Strength�and�stability�combination

Co�contraction�of�key�muscles

Incorporate�postural�awareness

Improve�precision�of�movement

119 Object�step�overs

Promotes�postural�stability�and�awareness

Promote�correct�midline�orientation�during�dynamic�gait�tasks

120

33

Tai�Chi�inspired�step�walking

Promote�control�in�single�limb�

support

Improve�step�length

Promote�increased�postural�awareness�and�proprioception

Promote�proper�gait�

mechanics

121

Rebounder�while�standing�on�compliant�surface

Rebounder�with�forward�step

Improve�reaction�timing

Can�be�tailored�to�patient�abilities

Vary�standing�surface�to�make�it�a�multi�modal�

activity

122

Trampoline�standing�with�reaching�outside�base�of�support

Rotation�to�incorporate�more�core�musculature

Ball�toss�&�catch�to�increase�difficulty

Total�body�

stability

Change�foot�

position�to�elicit�more�balance�strategies

123

Reaction�strategies

Dynamic�movement�outside�base�of�support

Stepping�strategies

Incorporates�UE�coordination

Dynamic�ball�push�and�react�activity�with�inclined�parallel�bars 124

Obstacle�course Single�leg�stance�on�compliant�surface

Great�way�to�simulate�obstacles�in�home�or�

community�settings

Environmental�awareness�training

Simulate�sharp�turns�or�figure�8�patterns

Unilateral�ankle�

strategy

SLS�progression

Balance�pads�come�in�various�levels�of�difficulty

125Wobble�board�standing

Medial�lateral�weight�shifting

Great�way�to�elicit�ankle�and�hip�strategies

126

34

Wobble�board�standing

Anterior�posterior�weight�shifting

Staggered�stance��

progression

127 Theraball leg�liftsTheraball diagonalsTheraball reaching

Pelvic�stabilization

Quad�control

Full�core�activation

Functional�activities

Static�or�dynamic

Increase�difficulty�by�changing�foot�or�arm�

position 128

Pulley�diagonals�on�theraball

Great�way�to�incorporate�UE�during�stability�training

Total�body�coordination

Functional�diagonals

129

Other�things�to�incorporate�with�the�high�level�patient

• Carrying�objects�across�a�room�(kitchen,�bedroom,�etc.)

• Reaching�to�floors�and�into�cabinets

• Laundry�tasks

• Retrowalking

130

Incorporate�realistic�balance�challenges�into�ADLs

Balance�tasks�that�translate�to�necessary�activities�in�the�home�

environment

131

Functional�balance�training

Functional�reaching�tasks 132

35

Functional�weighted�

carrying�task

Dynamic�functional�stability�&�

coordination

133

Practice�with�appropriate�

compensatory�strategies/devices�to�improve�

independence�

Good�opportunity�to�educate�regarding�safety�

awareness 134

What�about�the�low�level�patient?• Proximal�before�distal!�

• If�sitting�balance�is�impaired,�start�there

• Targeting�the�core�from�various�positions

• Crossing�midline• Functional�diagonal�movements�are�a�great�tool

• Moving�outside�of�base�of�support

• Weight�shifting135

Trunk�rotation�in�ball�assisted�kneeling

Trunk�rotation

Joint�approximation

Tone�reduction

Core�activation

136

Modified�sit�up

Modify�&�progress�

activity�easily

Good�way�to�show�progress 137

Supine�oblique�reaching

Easily�performed�in�bed�or�on�

mat

Great�carryover�to�bed�mobility�

tasks

Incorporates�both�core�and�UE�motion

Crossing�midline

138

36

Supine�modified�crunch

Improves�confidence�of�low�level�patient

139

Seated�reaching�activities

Sitting�balance�can�be�progressed�by�changing�chair�type

Can�be�done�from�wheelchair

Good�for�non�

ambulatory�patients

Function�&�attention�to�task�for�dementia�patients

Increase�patient’s�confidence�during�reaching�by�using�object�in�front�and�

behind�as�“safety�net”

Controlled�reaching�tasks

140

Bridging

GlutesCoreHamstringsPelvic�symmetry

Easily�progressed

Carryover�for�self�careQuads Great�for�

bed�mobility

141 Modified�quadruped�with�theraball

CoreJoint�

approximation

142

Quadruped

ProgressionJoint�approximation

143


144

37

What�about�the�patient�with�proprioceptive�deficits?�

•Proprioception�refers�to�the�ability�to�utilize�sensory�information�to�understand�where�one’s�body�parts�are�in�space– peripheral�kinesthetic�sense

• Impaired�proprioception�can�have�a�significant�effect�on�balance�and�safety�awareness

145

Propriceptive Deficits• Retropulsion• The�patient�who�is�constantly�leaning�backward�and�often�reports�falling�backward

• Incorrect�perception�of�midline�– patient�feels�like�leaning�backward�is�midline�so�anything�anterior�to�that�feels�like�falling

• Often�seen�in�patients�with�fear�of�falling�

146

Proprioceptive�Deficits• How�do�we�address�retropulsion?• Start�with�the�basics

• Promote�a�proper�sit�to�stand�transition

• Patient�must�be�re�acclimated�to�midline

• Place�patient�against�a�wall�– this�will�remove�the�option�of�leaning�backward• Progress�to�reaching,�forward�flexion,�moving�away�from�wall

• Unsupported�standing�progression147 Wall�Standing

Great�way�to�promote�proper�standing�posture

Midline�orientation

Easily�progressed�

with�reaching�tasks

Can�be�done�in�any�setting�and�with�little�space

148

Proprioceptive�Deficits• Impaired�lower�extremity�sensation• Compensatory�strategies�• Teach�patient�to�“feel”�proper�center�of�mass�over�base�of�support�position�• Visual�cues�• Focus�on�righting�strategies• Ankle�strength�and�stability�very�important�• Teaching�multi�tasking�very�important

• i.e.�scanning�environment�during�ambulation,�head�turns

• Assistive�devices�are�very�helpful�in�this�population

149

Gait�Abnormalities�that�Play�a�Role�in�Falls

150

38

Gait�Terminology�Review• Traditional/Ranchos�Los�Amigos• Stance�Phase

• Heel�strike/Initial�Contact

• Foot�flat/Loading�response

• Midstance/Midstance• Heel�off/Terminal�stance

• Toe�off/Preswing

• Traditional/Ranchos�Los�Amigos• Swing�Phase

• Acceleration/Initial�swing

• Midswing/Midswing• Deceleration/Terminal�Swing

151

Correction�of�Gait�Abnormalities�

• Foot�Drop

• Scissoring�

• Trendelenburg�

• Slow�walking�speed

• Parkinsonian�Gait�Deficits

152

Foot�Drop

• Often�a�result�of�neurological�impairments

•Weakness�or�misfiring�of�tibialis�anterior�muscle

• Patient�unable�to�utilize�proper�heel�to�toe�gait�pattern

• Places�patient�at�high�risk�for�falls�due�to�“toe�drag”�

153

Foot�Drop:�Ankle�Foot�Orthoses�(AFO)

154

AFO:�Posterior�Leaf�Spring

155

AFO:�Posterior�Leaf�Spring

• Custom�or�off�shelf

•Mild�to�moderate�foot�drop

• During�early�stance�the�upright�bends�backward�slightly�when�patient�applies�force�to�foot

•When�patient�progresses�into�swing�phase�the�plastic�recoils�forward�to�lift�foot

156

39

AFO:�Solid�Ankle

157

AFO:�Solid�Ankle

• Custom�only

•More�options�for�control�of�medial�lateral�instability

• Can�be�set�in�varying�degrees�of�ankle�dorsiflexion�or�plantarflexion

• Can�accommodate�for�edema�or�contractures

• Bulkier�than�posterior�leaf�spring158

AFO:�Toe�off

159

AFO:�Toe�off

• Off�shelf,�carbon�fiber�AFO

•Mild�to�severe�foot�drop

•Mild�to�moderate�ankle�instability

• Not�indicated�in�cases�of�severe�spasticity�or�edema

160

AFO:�Other�considerations

•Can�the�patient�don/doff�the�AFO?• If�not,�why�not?• Cognition• Fine�motor�skills• Range�of�motion

161

Foot�Drop

• Electrical�Stimulation•Neurological�Re�education•Muscle�Re�education�•Which�wave�forms�are�best:• NMES�(Neuromuscular�electrical�stimulation)• VMS• VMS�burst�

162

40

Foot�Drop:�Electrical�Stimulation�Placement

163

Foot�Drop:�Electrical�Stimulation�Placement

Two�2x2�electrodes Four�2x2�Electrodes

164

Foot�Drop• Electrical�stimulation�settings:• Amplitude�(mA):�varies�based�on�patient’s�tolerance

• Increases�depth�of�penetration• Increases�number�of�neurons�depolarized• For�muscle�re�education�and�neuro�re�education�increase�until�contraction�seen

• Frequency:�35�or�50�pps• 35�pps:�slow�twitch• 50�pps:�fast�twitch

• Easier�to�recruit• Quicker�fatigue

• Phase�Duration�(Carrier�Frequency)• 200�microseconds�or�greater�for�muscle�strengthening

165

Foot�Drop

• Electrical�stimulation�settings• Duty�cycle• Early�pre�CVA�or�post�surgical�long�on/off�times�to�allow�for�patient�to�perform�contraction�or�task• Ex.�10/50,�10/30

• As�patient�becomes�stronger�shorten�on/off�times�to�simulate�functional�activation• Ex.�4/12,�5/5

166

Foot�Drop

• Lema (lower�extremity�mobility�aide)�Strap

167

Scissoring

• Frequently�seen�in�patients�with�ataxia�– very�narrow�base�of�support�and�crossing�over�of�the�lower�extremities

•Often�a�coordination�deficit�and�not�a�pure�strength�deficiency�

168

41

Scissoring

• Increasing�base�of�support�to�increase�stability• Start�basic• Pre�gait�stepping�strategies• Tai�Chi�stepping�tasks• Standing�coordination�tasks�that�promote�increased�base�of�support

• Visual�feedback• Create�a�”pathway”�with�appropriately�spaced�tape�to�acclimate�patient�to�maintaining�a�wider�base�of�support�during�ambulation

169

Exaggerated�pathway

Visual�feedback�to�improve�base�of�support

Great�way�to�re�train�proper�mechanics�in�

patient�with�coordination�deficits

170

Alternating�cone�tapping

Great�for�ataxia�or�other�

coordination�deficits

Promotes�concentric�

and�eccentric�muscle�controlCarryover�with�

increased�step�length�during�reciprocal�movement� 171

Trendelenburg�

• Presents�as�a�“dropping”�of�the�pelvis�during�swing�phase

• Leads�to�increased�energy�expenditure�during�ambulation�– reduces�gait�efficiency�and�endurance

• Indicates�weakness�of�the�_____________

172

Trendelenburg

• Exercises�to�target�the�gluteus�medius• Clamshells

• Sidelying abduction

• Standing�abduction

• Side�stepping

• Bridging�with�theraband resistance173 Resisted�clamshells

Sidelying abduction

174

42

Bridging�with�resisted�abduction

175

Resisted�side�stepping

176

Side�step�ups

Promotes�pelvic�stability

177

Slow�Walking�Speed

•Walking�speeds�of�>1.0�m/s�indicate�a�lower�risk�for�falls

•Average�walking�speed�for�individuals�who�were�independent� with�daily�activities�was�found�to�be�1.11�m/s

•Normal�walking�speed�is�1.4�m/s

178

Slow�Walking�Speed

•An�increase�of�0.1�m/s�considered�a�predictor�in�well�being

179

Improving�Walking�Speed

•Promote�increased�step�length

• Increase�patient’s�walking�cadence•Metronome• Counting�

180

43

Parkinsonian�Gait�Deficits• Difficulty�with�initiation• Shuffling• Freezing• Rigidity• Bradykinesia�(slow�movements)• Akinesia�(hesitancy)• Hypokinesia (reduced�amplitude)

181

Parkinson’s�Treatment

• In�recent�years,�treatment�of�Parkinson’s�Disease�has�shifted�from�reactive�to�preventative�

•What�is�LSVT?�–Lee�Silverman�Voice�Treatment�began�with�LOUD,�focusing�on�the�speech�motor�system�

• Extended�to�LSVT�BIG,�focusing�on�limb�motor�systems�in�individuals�with�Parkinson’s�Disease

182

Parkinson’s�Treatment:�LSVT�BIG• Promote�exaggerated�movements�with�increased�amplitude

• Leads�to�increased�speed�and�precision�of�movement�

• Continuous�feedback�on�motor�performance�provided�to�counteract�reduced�gains�due�to�impaired�sensorimotor�processing

• Repetition�of�tasks�is�utilized�to�promote�carryover–minimum�of�15�repetitions�

• Visual�feedback,�i.e.�video�of�patient�walking�to�show�that�their�“big”�movements�are�actually�normal�movements�

183

Resources:�LSVT�BIG�Certification

•www.lsvtglobal.com

• 2�day�course

184

Upper�Extremity�Contributors�to�Poor�

Gait�Mechanics

185

Upper�Extremity�Contributors

• Flaccid�upper�extremity

•Upper�extremity�weight�bearing�restrictions

186

44

Flaccid�Upper�Extremity

• Limits�types�of�assistive�devices�that�may�be�utilized

•Causes�asymmetrical�weight�distribution�in�standing

187

Stabilizing�Flaccid�or�Hemiplegic�Upper�Extremity

• Slings• GivMohr• Anti�subluxation• Avoid�slings�that�place�shoulder�in�horizontal�adduction

• Elastic�taping

188

Assistive�Device�Options�for�Patients�With�Flaccid�or�Hemiplegic�Upper�

Extremity• Hemi�walker

• Standard�or�rolling�walker�with�hand�strap

•Quad�cane•Wide�based• Small�based

• Single�point�cane189

Upper�Extremity�Weight�Bearing�Restrictions

• Limits�the�type�of�assistive�devices�that�may�be�utilized�

190

Options�For�Lessening�Impact�of�Upper�Extremity�Weight�Bearing�

Restrictions�on�Gait• Splinting

• Slings

• Add�platform�to�walker�depending�on�location�of�injury

• Use�of�single�UE�device• Quad�cane,�single�point�cane,�hemi�walker

191

Special�considerations�for�patient�with�precautions

•Hip�precautions•With�posterior�hip�precautions�adaptive�equipment�is�very�important�to�allow�the�patient�to�maintain�precautions• Reachers• Sock�aides�• Elevated�toilet�seat• Long�handled�sponge• Shoe�horn• Elastic�shoe�laces

192

45

Special�considerations�for�patients�with�precautions

•Back�precautions• Patient�restricted�from�bending,�twisting,�lifting

• TLSO�or�LSO�may�be�ordered�by�surgeon• Can�patient�don�and�doff?

• Adaptive�equipment�will�be�necessary�to�maintain�precautions�with�some�activities

193

Special�considerations�for�patients�with�precautions

• Sternal�precautions• No�pushing,�pulling,�lifting,�reaching�overhead,�limited�or�no�UE�weighted�exercise• Lower�extremity�strength�very�important�for�this�patient�–especially�quadriceps• Must�be�trained�to�sit�to�stand�without�use�of�upper�extremities• Education�regarding�sternal�incision�important• Frequent�short�walks�are�indicated• Pacing�very�important�with�this�patient

194

Improving�balance�in�the�patient�with�lower�

extremity�weight�bearing�restrictions

195

Review:�weight�bearing�precaution�definitions

*adapted�from�the�Orthopedic�Specialists�of�North�Carolina�guidelines*

• Non�weight�bearing�(NWB)• No�weight�placed�on�injured�leg• Injured�leg�must�be�held�off�of�floor�when�standing�or�walking

• Toe�touch�weight�bearing�(TTWB)�or�touch�down�weight�bearing�(TDWB)• Injured�leg�can�only�touch�floor�for�balance• No�body�weight�should�be�placed�on�leg• Imagine�there�is�an�egg�under�foot�that�you�are�not�to�crush

196

Review:�weight�bearing�precaution�definitions

*adapted�from�the�Orthopedic�Specialists�of�North�Carolina�guidelines*

• Partial�weight�bearing�(PWB)• When�standing�or�walking�some�of�weight�may�be�placed�on�injured�leg• Doctor�decides�on�exact�percentage�of�weight�allowed

• Weight�bearing�as�tolerated�(WBAT)• When�standing�or�walking�patient�may�place�as�much�weight�on�leg�as�feels�comfortable• Amount�of�weight�bearing�is�guided�by�pain

• Full�weight�bearing�(FWB)• No�restriction�– full�weight�on�leg

197

Addressing�balance�in�patient�with�weight�bearing�restrictions

• Strengthening• Limb�not�being�used�normally�for�weight�bearing�tasks�• Important�to�address�strength�to�reduce�muscle�wasting/atrophy�• Upper�extremity�strength�is�very�important�for�proper�adherence�to�weight�bearing�restrictions�during�standing�and�walking�tasks

• Keep�the�core�strong• Seated�activities�on�a�ball• Place�BOSU�or�foam�mat�in�a�chair�and�have�patient�do�activities�while�on�compliant�surfaces

• Progress�to�single�leg�stance�activities�in�unilateral�NWB�and�TTWB�patient

198

46

Compliant�surface�sitting�balance�tasks� 199 BOSU�sitting�activities

Increase�difficulty�of�core�stability�tasks�when�LE�

WB�restrictions�present

200

Step�standing�during�exercise�with�unilateral�WB�restrictions

Unilateral�standing�hip�abduction

Unilateral�standing�hip�flexion�with�knee�

extended

Unilateral�standing�hip�extension 201

Reducing�Fall�Risk�in�the�Patient�with�Lower�

Extremity�Amputation

202

Stages�of�Amputee�Rehabilitation

1. Immediate�Post�operative�Stage:�Limb�Immobilized

2. Immobilization�Removed:�pre�prosthetic�phase

3. Intermediate�Stage:�Incision�healed�&�weight�bearing�activities�may�begin,�including�ambulation

4. Advanced�Stage:�Agility�and�endurance�training

5. Return�to�prior�activities:�Independent203

Amputees

• This�population�is�at�a�high�risk�for�falls�due�to�the�change�of�center�of�mass

• Bilateral�amputees�are�at�higher�risk�for�falls�from�wheelchairs�due�to�top�heavy�weight�distribution

• Proper�wheelchair�selection�is�very�important�for�these�patients• Amputee�pads• Front�and�back�anti�tippers

204

47

Balance�Training�for�the�Amputee

• Sitting�balance• Because�of�the�change�of�weight�distribution,�patient�must�re�learn�proper�displacement�of�center�of�mass�(COM)�over�base�of�support�(BOS)

• Long�sitting�activities�are�a�great�starting�point

•Manual�resistance• Perturbations• PNF�techniques�(i.e.�alternating�isometrics,�rhythmic�stabilization)

205

PNF�Technique:�Alternating�isometrics

Core�stabilization�

Isometric�contraction�of�

agonist�movement�followed�by�antagonist�movement

Isometric�trunk�flexion Isometric�trunk�extension206

PNF�technique:�Rhythmic�StabilizationIsometric�co�contraction�of�muscles�surrounding�target�area

Co�contraction�with�patient�performing�

isometric�trunk�flexion�on�one�

side�and�isometric�trunk�extension�on�the�other�– rotational�

stabilization�effect

207


• Sitting�Balance• Trunk�rotation�and�reaching�tasks�will�improve�dynamic�sitting�abilities• Add�resistance�using�theraband or�pulleys

• Sitting�on�compliant�surface�to�further�challenge�patient• i.e.�Foam�mat,�BOSU,�Theraball• Incorporate�multi�directional�reaching�&�diagonals�

• Sitting�with�ball�toss• Progress�with�weighted�ball• Vary�direction�of�throws

208

Balance�Training�for�the�Amputee• Pre�prosthetic�training:• Developing�increased�hip�muscle�control�is�essential�for�progression�to�prosthetic�use,�especially�in�the�above�knee�amputee�(AKA)

• Quadruped�activities�facilitate�strength�through�weight�bearing�and�joint�approximation• Progress�to�arm�lifts/leg�lifts

• Tall�kneeling�facilitates�strengthening�of�core,�pelvis,�and�hip�musculature

• Displacement�of�COM�over�BOS�in�tall�kneeling�is�a�great�precursor�to�balancing�over�prosthesis�with�mechanical�knee�and�ankle�joints

209


• Prosthetic�training�• Control�of�anatomical�and�prosthetic�knee�and�ankle�joints�is�key

• Symmetrical�weight�bearing�– teach�patient�proper�alignment�so�patient�can�feel�through�residual�limb�(pressure�change�in�socket)�what�that�position�is�

• Diagonal�weight�shifting�– patient�shifting�from�prosthetic�heel�to�sound�toe�and�the�opposite

210

48


• Prosthetic�training• Single�leg�stance�is�important�for�progression�to�proper�gait�mechanics• Without�proper�ability�to�maintain�single�leg�stance�gait�deviations�will�be�present

• Stepping�up�with�sound�limb�to�promote�stance�through�prosthesis

•Manual�perturbations�in�standing�with�prosthesis

211


•Progress�to�unsupported�balance�tasks

•When�stability�improves�patient�can�be�progressed�to�high�level�balance�challenges�that�we�would�use�with�our�non�amputee�patients

212

Preparing�Clients�for�Re�integration�to�home�and�

community

213

Home�Exercise�Program

• Continued�activity�following�discharge�is�important�in�the�maintenance�of�functional�gains

• Provide�patients�with�3�5�exercises�that�can�be�completed�safely�in�the�home

• Provide�photographs�and�descriptions�to�ensure�proper�completion�of�exercises

214

Quick�Resource�for�Home�Exercise�Programs

•www.hep2go.com

215

OTAGO

• Exercise�program�to�prevent�falls�in�older�adults�

•Created�by�Accident�Compensation�Corporation�(ACC)�in�New�Zealand

216

49

OTAGO• A�set�of�lower�extremity�strengthening�and�balance�retraining�exercises�with�progressive�difficulty�designed�to�prevent�falls

• Participants�are�expected�to�complete�strength�and�balance�exercises�3�times�per�week�and�walking��program�twice�a�week

• Participants�record�their�progress�and�instructor�(therapist)�follows�up�via�phone�or�home�visit�once�per�month

• Follow�up�face�to�face�visits�are�recommended�every�6�months

217

OTAGO�

•Program�found�to�reduce�falls�and�fall�related�injuries�by�35%

•Recommended�for�individuals�80�and�over�with�have�fallen�in�the�past�year

•OTAGO�training�for�physical�therapists�is�available�online�and�through�some�employers

218

Preparing�Patients�for�the�Unexpected

I�Fell…Now�what?

219

Floor�Transfers

220

Other�Considerations�for�the�High�Fall�Risk�Patient

• Emergency�Medical�Alert�Devices• Cellphone• Carried�on�person�at�all�times�when�alone

• Landline�phones�in�every�room�of�home• Monitor�systems• For�patients�who�live�with�caregivers�or�family�members

• Retractable�keychains• Cane�straps

221

Home/Community�Readiness�Checklist

�Gait�training�on�uneven�surfaces�Curb�negotiation�Step�negotiation�Side�stepping�Backward�stepping�Retrieving�items�from�high�and�low�surfaces�Carrying�objects�while�ambulating�Floor�transfers�Emergency�plan

222

50

Appropriate�DME�Recommendations

223

Medicare�Guidelines�for�DME�

•Documentation�should�include:• Physical�limitations�that�prevent�patient�from�completing�mobility�related�ADLs�in�the�home• Mental�capabilities�must�be�sufficient�for�safe�and�adequate�performance�of�mobility�related�ADLs�with�use�of�equipment• Physical�capabilities�are�sufficient�for�safe�and�adequate�performance�of�mobility�related�ADLs�with�the�use�of�equipment• Characteristics�of�home�are�suitable�for�use�of�appropriate�equipment• Patient�demonstrates�willingness�to�utilize�equipment�regularly

224

DME�Recommendations

•Based�on�individual�patient�presentation

•May�be�affected�by�other�co�morbidities

•Consider�ability�to�utilize�device�in�environment

225

Special�DME�Considerations:�Rollators

Great�for�energy�

conservation

Often�good�for�patients�with�

initiation�deficits�

or�freezing

Require�more�

coordination�and�stability�than�front�wheeled�walkers

Front�wheels�swivel

226

Rollator�walker

Four�wheeled�rolling�walker�with�seat

Front�wheeled�rolling�walker�with�seat

Other�Walker�with�Seat�Options

227

DME�Recommendations�

Shower�chair Vs. Tub�transfer�bench

228

51

Other�Recommendations

Hanging�shoe�rack Pant�clipPush�lights

229

Environmental�Modifications

If�Home�Assessment�is�Possible

230

What�is�the�safest�method�to�enter�home?

• If�there�are�multiple�options�for�entry,�which�is�the�safest?•Which�is�the�most�used�by�patient?

231

Hallways

•Are�they�wide�enough�for�patient’s�assistive�device�if�used?• If�not,�what�alternative�methods�are�appropriate?

•Are�hallways�free�of�clutter�and�tripping�hazards?

232

Bathroom

• Can�assistive�device�fit�through�bathroom�door?• If�not,�what�other�methods�can�be�utilized?

• Can�patient�safely�enter�and�exit�tub?��• If�not,�what�modifications�or�training�may�assist�with�this?

• Can�patient�transfer�onto�and�off�of�commode�safety?• If�not,�what�modifications�may�assist�with�this?

• Can�patient�access�items�in�cabinets�if�necessary?

233

Living�Area

•Can�patient�safety�transfer�onto�and�off�of�choice�seating?• If�not,�what�modifications�may�improve�this?

•Are�there�throw�rugs?• If�yes,�are�the�edges�secure?• Are�they�necessary?

•Does�the�area�have�sufficient�lighting?

234

52

Bedroom

• Can�patient�utilize�assistive�device�in�area?• Can�patient�access�closets�and�dresser�drawers�safely?• Can�patient�safety�transfer�onto�and�off�of�bed?• If�not,�what�are�some�suggestions?

• Is�there�a�restroom�available�in�room?• If�not,�is�a�bedside�commode�necessary�for�safety�during�the�night�hours?

• Is�patient�able�to�reach�light�source�from�bed?235

Pets

• Do�they�live�inside�the�home?

• Do�they�pose�a�tripping�hazard?

• Are�there�water/food�bowls�on�the�floor�in�walking�

areas?

• Does�the�patient�have�assistance�caring�for�them?

236

Home�Assessment�Findings

• Incorporate�home�assessment�findings�into�treatment�sessions�following�the�assessment�– this�may�require�adjustment�to�discharge�plan

• If�you�work�in�home�health�the�sky�is�the�limit�� every�treatment�session�is�an�opportunity�to�teach�a�patient�to�perform�better�in�their�own�environment

237

Environmental�Modifications

If�Home�Assessment�is�Not Possible

238

Replicating�patient’s�home�environment�in�clinic

• Ask�family�member�to�provide�photographs• Get�measurements�of:• Hallways• Doorways• Step�height• Seat�to�floor�height�for�seating�used�by�client• Height�of�bed• Toilet�height�

239

Side�stepping

Very�important�activity�for�most�home�settings

Replicate�width�of�patient�

halls/doorways�for�preparation

240

53

Moving�object�negotiation/pet�preparation

241

Documentation�of�Balance�Goals�and�Daily�

Treatment

242

Medicare�Documentation�Guidelines:�Plan�of�Care

• The�plan�of�care�should�contain,�at�minimum:• Diagnoses• Long�term�treatment�goals• Type,�amount,�duration�and�frequency�of�therapy�services• Amount�of�treatment�refers�to�the�number�of�times�in�a�day�the�type�of�treatment�will�be�provided

• Frequency�refers�to�the�number�of�times�in�a�week�the�type�of�treatment�is�provided

• Duration�is�the�number�of�weeks,�or�the�number�of�treatment�sessions

243

Medicare�Documentation�Guidelines:�Plan�of�Care

•When�devising�a�plan�of�care,�a�therapist�is�expected�to:• Establish�a�rehabilitation�diagnosis• Individualized�plan�for�each�patient�based�on�the�evaluation/examination• Establish�a�treatment�program• Specific�interventions�must�be�used�to�treat�the�patient’s�needs• (i.e.��Therapeutic�exercise,�functional�training,�manual�therapy�techniques,�adaptive�devices/equipment�needs,�modalities)

244

Medicare�Documentation�Guidelines:�Plan�of�Care�Continued

• Establish�anticipated�goals,�expected�outcomes,�any�predicted�level�of�improvement• Short�term�goals�(optional)• Long�term�goals• Determine�the�intensity,�frequency,�and�duration�of�care

• The�plan�of�care�includes�anticipated�discharge�plans

245

Medicare�Documentation�Guidelines:�Treatment�Encounter�Notes

• Record�of�all�treatment• Documentation�is�required�for�every�treatment�day,�and�every�therapy�service,�it�must�record�the:• Date�of�treatment• Treatment,�intervention,�or�activity• Total�timed�code�treatment�minutes�and�total�treatment�time�minutes�(includes�timed�and�untimed�codes)• Signature�and�professional�identity�of�qualified�professional�furnishing�treatment• Additional�information�may�be�included�(response�to�treatment,�changes) 246

54

Medicare�Documentation�Guidelines:�Treatment�Encounter�Notes

• Document�to�meet�requirements• Services�should�be�appropriate�type,�frequency,�intensity,�and�duration�for�the�individual�needs�of�patient• The�fact�that�services�are�billed�is�not�necessarily�evidence�that�they�were�appropriate• Documentation�of�objective�measures• Needs�of�patient

• Contributing�factors�i.e.�motivation,�cognition,�onset,�psychological�stability,�social�stability

247

Medicare�Documentation�Guidelines:�Reasonable�and�Necessary�Services• Services�meet�accepted�standards�of�medical�practice

• Specific�and�effective�treatment�for�the�condition

• A�level�of�complexity/sophistication�or�the�condition�of�the�patient�shall�be�such�that�the�services�required�can�be�safely�and�effectively�performed�only�by�a�qualified�therapist�(or�supervised�PTA/OTA),�and

• Patient’s�clinical�condition�requires�the�skills�of�a�therapist

248

Medicare�Documentation�Guidelines:�Services�Require�Skills�of�a�Therapist• Services�must�not�only�be�provided�by�the�qualified�professional,�but�they�must�require�the�expertise,�knowledge,�clinical�judgement,�decision�making�and�abilities�of�a�therapist�that�assistants,�qualified�personnel,�caretakers�or�the�patient�cannot�provide�independently

• A�clinician�may�not�merely�supervise,�but�must�apply�the�skills�of�a�therapist�by�actively�participating�in�the�treatment�of�the�patient�during�each�progress�reporting�period

249

Medicare�Guidelines:�Services�Require�Skills�of�a�Therapist

• A�therapist’s�skills�may�be�documented,�by�the�clinician’s�descriptions�of�their�skilled�treatment,�the�changes�made�to�the�treatment�due�to�a�clinician's�assessment�of�the�patient’s�needs�on�a�particular�treatment�day�or�changes�due�to�progress�the�clinician�judged�sufficient�to�modify�the�treatment�toward�the�next�more�complex�or�difficult�task

250

Documentation�of�Services�Related�to�Falls�and�Balance�Deficits

Now�that�we�have�the�Medicare�guidelines�down!

251 252

55

Goals�Recipe•Who?• Who�is�being�addressed�in�the�goal

•Action�words• Strong,�skilled�language�indicating�how�you�are�teaching�or�training

•Measure• Quantitative�or�qualitative�measurement�of�what�you�are�assessing

• Device:• Type�of�device�utilized�during�activity

• Time�Frame:• Based�on�therapist’s�judgement�after�reviewing�subjective�and�objective�findings�and�PLOF�information

•Why?• Explain�what�this�goal�will�accomplish 253

Who?

•Patient

•Caregiver

• Facility�staff

• Family�member254

Action�words�goal�examples�

• “will�demonstrate”

• “will�list”

• “will�report”

255

Measure• Standardized�assessment�score�(i.e.�46/56�on�BERG�balance�assessment)

• Muscle�grade�(i.e.�3/5�hip�flexor�strength)

• Balance�grade�(i.e.�Fair�dynamic�balance)

• Gait�speed�measurement�(i.e.�gait�speed�of�1.1�m/s)

• Gait�distance�(i.e.�150�feet)

• Level�of�assistance�(i.e.�Standby�assistance)256

Device• “Without�assistive�device”

• “With�rolling�walker”

• “With�single�point�cane”

• “At�wheelchair�level”

•With�hemi�walker” 257

Time�Frame

• “in�two�weeks”

• “In�four�weeks”

• Based�on�evaluation�time�frames�selected�by�therapist

258

56

Why?• “To�promote�return�to�prior�level�of�function

• “To�reduce�risk�for�falls�and�improve�functional�independence”

• “to�promote�return�to�prior�living�setting”

• “to�reduce�caregiver�burden”�

259

Goals:�Case�Example�– Mr.�Jones

• 72�year�old�male�who�lived�independently�in�single�level�home�with�3�steps�to�enter�with�hand�rail�on�right�side�going�up.��

• Was�independent�with�all�mobility,�ADL,�and�IADL�and�managed�all�medication�and�finances

• He�did�not�use�any�assistive�devices�prior�to�hospitalization

• He�has�a�walk�in�shower�without�shower�chair�and�handheld�shower�head

• He�was�driving�and�volunteered�at�the�senior�center�3�days�a�week

260

Goals:�Case�Example�� Mr.�Jones

• Mr.�Jones�was�hospitalized�for�5�days�with�community�acquired�pneumonia�and�has�now�completed�antibiotic�course�and�has�been�admitted�to�rehab�in�skilled�nursing�facility

• On�evaluation�Mr.�Jones�required�contact�guard�assistance�for�sit�to�stand�and�was�able�to�ambulate�150�feet�using�rolling�walker�with�contact�guard�assistance�before�needing�to�sit�due�to�fatigue

• BERG�balance�assessment�score�was�38/56�and�TUG�test�was�performed�in�36�seconds�using�a�rolling�walker

261


• He�completed�shower�with�contact�guard�assistance�to�transfer�to�shower�bench�and�bathed�upper�body�with�set�up�and�required�Min�A�for�lower�body�bathing�secondary�to�difficulty�maintaining�sitting�balance�while�lifting�foot�off�of�floor

• He�was�able�to�don�shirt�with�Mod�I�and�required�Min�A�for�lower�body�dressing�and�clothing�management�due�to�instability�in�standing

262


• Using�our�goals�cookbook�as�a�reference,�write�a�recipe�for�Mr.�Jones’�short�term�and�long�term�goals

• Be�sure�to�focus�on�areas�that�will�increase�his�safety�and�promote�return�to�independence�

263 264

57

265 266

Daily�Documentation�Recipe

• Who?• Who�is�being�addressed�in�the�activity?

• Action�words• Strong,�skilled�statements

• What?• Name�specific�activity�or�exercises

• How?• What�are�specific�details�of�activity?

• Cuing?• What�cuing�strategies�were�utilized?

• Why• What�is�the�benefit�of�this�activity?

• Patient�Response• What�are�objective�or�subjective�patient�responses�noted�during�treatment?�

267

Who?

•Patient

•Caregiver

• Facility�staff

• Family�member268

Action�words:�DDo’s

• Instruct• Direct• Educate• Create• Train• Demonstrate• Problem�Solve• Stabilize

• Plan• Assess• Formulate• Solve• Grade• Develop• Adapt• Challenged

269

Action�Words:�DDont’s

• Helped• Motivate• Assisted• Encouraged• Patient�Seen

• Monitor• Slow�progress• Repeated• Review• Practice

270

58

Action�words�daily�notes�examples

• “was�instructed�in”

• “was�educated�regarding”

• “was�assessed”

271

What?

• “dynamic�standing�on�foam�while�reaching�outside�base�of�support”

• “obstacle�negotiation�on�even�surfaces”

• “step�negotiation�using�unilateral�hand�rail”

272

How?

• “without�assistive�device”

• “with�single�upper�extremity�support”

• “with�contact�guard�assistance”

273

Cuing

• “with�verbal�cues�for�environmental�awareness”

• “with�tactile�cues�for�posture”

• “with�visual�cues�to�promote�increased�base�of�support”�

274

Why?

• “to�elicit�ankle�and�hip�strategies�to�improve�patient’s�righting�responses�and�reduce�risk�for�falls”

• “to�improve�postural�awareness�during�activities�of�daily�living�to�promote�increased�stability�and�functional�independence”

275

Patient�Response

• “patient�had�two�episodes�of�loss�of�balance�during�turning”

• “patient�demonstrates�increased�trunk�control�with�repetition�of�activity”

• “patient�required�seated�rest�break�following�bout�secondary�to�fatigue”

276

59

Daily�Notes:�Case�Example�– Mr.�Jones

• During�his�treatment�session�today�Mr.�Jones�completed�balance�activities�lead�by�his�physical�therapist• Mr.�Jones�stepped�onto�foam�mat�and�therapist�asked�Mr.�Jones�to�move�his�feet�apart�to�steady�himself• Mr.�Jones�performed�activity�where�he�reached�in�various�directions�while�remaining�on�foam�mat• Mr.�Jones�lost�his�balance�twice�during�this�task�but�he�was�able�stabilize�at�the�ankles�to�correct�balance�without�assistance�from�therapist• The�therapist�remained�in�contact�with�the�patient�to�steady�him�if�needed�but�did�not�provide�physical�assistance�during�task

277

Daily�Notes:�Case�Example�– Mr.�Jones

•Use�your�daily�notes�recipe�to�create�a�daily�documentation�note�for�Mr.�Jones

278

279 280

Documentation�and�Productivity

•Productivity�varies�in�each�setting

•One�common�theme�across�settings�is�the�rise�of�productivity�standards

•What�effect�do�productivity�standards�have�on�you�as�a�therapist?

281

Documentation�and�Productivity• What�are�some�ways�to�improve�productivity?• Point�of�service�documentation

• When�we�provide�this�type�of�documentation,�it�is�important�that�we�incorporate�the�patient• Document�during�therapeutic�rest�breaks• Standing�desks�for�therapists• During�evaluation�and�progress�reports�discuss�the�information�you�are�inputting�and�how�it�affects�the�patient• This�is�a�great�time�to�ask�the�patient�how�they�feel�they�are�progressing• Get�patient�input�on�goals�and�progress

282

Additional Supplements are available at the below link:https://blog.summit-education.com/singleton/

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References

Alzheimer’s Association. “What is Alzheimer’s?” “Dementia with Lewy Bodies.” “Vascular Dementia.” www.alz.org. Web. 12 Feb. 2017. American Macular Degeneration Foundation. “What is Macular Degeneration?” www.macular.org. Web. 05 Mar. 2017. Anacker, S. and Difabio, R. (2016). Influence of Sensory Inputs on Standing Balance in Community-Dwelling Elders with a Recent History of Falling. Physical Therapy, 72 (8). 575-581. Avin, K., et. al. (2015). Management of Falls in Community Dwelling Older Adults: Clinical Guidance Statement from the Academy of Geriatric Physical Therapy of the American Physical Therapy Association. Physical Therapy, 95 (6). 815-834. Campbell, S. (2005). Deteriorating Vision, Falls, and Older People: The Links. Published by Visibility. ISBN 0 951 52874 2. 1-43. Centers for Medicare & Medicaid Services. www.cms.gov. Web. 8 Mar 2017. Fischer, B., et. al. (2014). Declining Cognition and Falls: Role of Risky Performance of Everyday Mobility Activities. Physical Therapy, 94 (3). 355 362. Fox, C., et. al. (2012). LSVT LOUD and LSVT BIG: Behavioral Treatment Programs for Speech and Body Movement in Parkinson Disease. Hindawi Publishing Corporation. Parkinson’s Disease, 2012, Article ID 391946. 1-12. Gailey, R. and Gailey, A. (1994). Balance, Agility, Coordination, and Endurance For Lower Extremity Amputees. Miami, Florida. Advanced Rehabilitation Therapy Incorporated. Kirkness, C., et. al. (2015) Race Differences: Use of Walking Speed to Identify Community Dwelling Women at Risk for Poor Health Outcomes-Osteoarthritis Initiative Study. Physical Therapy, 95 (7). 955-965. Landers, M., et. al. (2016). Balance Confidence and Fear of Falling Avoidance Behavior are Most Predictive of Falling in Older Adults: A Prospective Analysis. Physical Therapy, 96 (4). 433-442. Letgers, K. (2002). Fear of Falling. Physical Therapy, 82 (3). 264-272. Norkin, C. and White, D. (2003). Measurement of Joint Motion: A Guide to Goniometry 3rd edition. Philadelphia, Pennsylvania. F.A. Davis Company. O’Sullivan,S. and Schmitz,T. (2007). Physical Rehabilitation Fifth Edition. Philadelphia, Pennsylvania. F.A. Davis Company. Protas, E., et. al.(2005)Gaitand Step Training to Reduce Falls in Parkinson’s Disease. NeuroRehabilitation, 20. 183-190. Shumway-Cook, A., et. al. (2009). Falls in the Medicare Population: Incidence,Associated Factors,and Impact on Healthcare. Physical Therapy, 89 (4). 324-332. Stubbs, B., et. al. (2015). What Works to Prevent Falls in Community-Dwelling Older Adults? Umbrella Review of Meta-Analyses of Randomized Controlled Trials. Physical Therapy, 95 (8). 1095-1110.

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Fall Prevention Strategies