Fall Risk Reduction Program

Module #6 of 6

Shelley Thomas, MPT, MBADara Coburn, M.S., CCC-SLP

Fall Risk Reduction Program: Review of Modules 1 - 5

In the first module we reviewed the premise of the Fall Risk Reduction Program, including the inclusion criteria for patient selection.

The second module reviewed patient assessment Identifying patients at risk of falling Evaluating patients in a dual task condition to simulate “real life”

situations The third module covered how to determine which systems of balance

were weakest and develop an exercise program for those systems. The fourth module looked at IM scores and how to utilize them to

establish treatment plans, how to advance exercises based on domains of challenge, and how to gauge progress through reassessment.

In the fifth module, we discussed discharge planning and establishing effective home exercise programs.

Module 6 Agenda

Review a case study from start to finish Patient suitability Patient evaluation Determine balance systems impacted Establish treatment plan Advancing the exercises Determining when to discharge Home exercise planning

Case StudyIs this patient a suitable candidate for an

IM Fall Risk Reduction Protocol

73 year old male with history of three falls in the last two months.

Had L2-5 laminectomy and fusion (July, 2011) Past medical history significant for CABG x 4

(2010) with documented anoxic event during surgery

Patient and family report cognitive changes after heart surgery.

The patient reports he is still “not quite right”.

Case StudyIs this patient a suitable candidate for an

IM Fall Risk Reduction Protocol

Lives alone in 2 story home with 4 steps to enter and 14 steps inside home.

Hires help with housework and cooking. Receives Meals on Wheels. Family assists with finances and checks

on patient several times per week. Was participating in regular exercise

program until back problems worsened.

Case StudyIs this patient a suitable candidate for

an IM Fall Risk Reduction Protocol

Patient described his falls as “stupid” and “exasperating”. Fall 1: He caught his toe on a change of surface (moving

from carpet to linoleum). Fall 2: Walking to the mailbox and slipped. Reported he

“wasn’t paying enough attention”. Fall 3: In a parking lot. Patient reports he got distracted by

another person and “mis-stepped”.

Referred for physical and speech therapy to address balance and cognitive deficits.

Case Study: PT Evaluation ROM: No significant limitations Strength: 4/5 throughout upper and lower

extremities. Proprioception: Intact Vestibular: Unable to walk with

horizontal head turns without loss of balance. Also demonstrates LOB with eyes closed activities.

Endurance: Fair – patient reports fatigue after 5-10 reps of exercise

Case Study: PT Evaluation

TUG = Timed Up and Go

Test Patient Score

At High Risk for Falling if:

TUG alone: 11 seconds > 14 seconds

TUG Cognitive:

16 seconds > 14.5 seconds

TUG Manual: 18 seconds > 15 seconds(Shumway-Cook, Brauer, & Woollacott, 2000)

Case Study: ST EvaluationSubtests from the Ross Information Processing Assessment-Geriatric (RIPA-G), were administered to assess memory and processing skills.

* Within Normal Limits

Subtest Standard Score Severity Rating

Immediate Memory 9 ModerateRecent Memory 13 MildTemporal Orientation 12 ModerateSpatial Orientation 8 ModerateOrientation to Environment 13 MildRecall of General Info 15 WNL*Problem Solving and Reasoning 13 Mild

Case Study: ST EvaluationSubtests from the Ross Information Processing Assessment-Geriatric (RIPA-G), were administered to assess memory and processing skills. Subtest Standard Score Severity Rating

Organization of Information

8 Moderate

Auditory Processing and Comprehension

13 Mild

Problem Solving and Concrete Reasoning

16 WNL

Naming Common Objects

19 WNL

Functional Oral Reading

19 WNL

Case Study “Patient Selection Worksheet” from Module 2

LFA

Case Study “Designing an Exercise Program” Worksheet from Module 3

Case Study “Designing an Exercise Program” Worksheet from Module 3

How to Develop and Advance Treatment Plan

Problem

Areas

Musculoskeletal System

Proprioceptive System

Vestibular System

Oculomotor System

Cognition, Communicati

on

Strengthening exercises, postural reeducation, balance strategiesChallenge

cognition/communication, recall, word finding, impulse control, sorting, sequencing, divided and selective attention

Uneven surfaces, eyes closed, head turns with gait, spinning, changes of direction

Treatment Plan

Received PT and ST, 2x/week x 6 weeks

1 hours sessions per discipline

Performed approximately 30 minutes of IM 2x/week x 6 weeks

Sample Case Study Treatment PlanSession #: Session 1 Session 2 Session 3 Session 4 Session 5 Session 6 Session 7 session 8 Session 9 Session 10 Session 11 Session 12Total Time: 40 25 28 30 34 33 32 34 35 32 34 47Long Form Assessment 15 15Phase 1, 2, 3 activities 25 25Leg Squats 2 2 2 2Lunges 2 2 2 2Heel Raises 2 2 2 2 2 2 2 2 2 2Long Arc Quads 2 2Taps Ups 2 2Lateral Tap Ups 2 2Alternate Stepping 2 2 2 2 2 2 2 2Stepper with WeightsBridging 2 2 2 2Abdominal Crunch 2 2 2 Postural AlignmentPostural Alignment with Marching 2Clock Uneven Surface with Eyes Open Uneven Surface with Eyes Closed 3 4Clapping with Eyes Closed, Seated 2Clapping with Eyes Closed, Standing UNO Poster BoardVisual MemoryVisual SequencingRecall/recognitionHead Movement in Supine 2 Head Movement in Sitting 2 2 2Head Turns with Reaching Across Midline 2 4 2 2Head Turns with Walking 2 2 2 2 2 2 2RollingSidelying to Sit with Head RotationVisual tracking focal item 2 2In Sitting, Head stationary, Saccades 2 2 2 2 2Using the in-Motion Triggers 6 6 6 6 6Seated, Reaching Across and Behind to hit target 2 2 2 2STROOP Activities 2 2 2 2 3 2 3Aphabetizing 2 2 2 3Sorting 2 2 2 3Sequencing 2 2 2 2 2 2 3Impulse ControlSafety AwarenessSelected and Divided Attention 2 2 2 2 3 3 3 3Visual Attention 2 2 2 3 3Memory 4 4 6 6 4 4 5 5 5 5Yes/No Questions 2 2 2 2NamingWord FindingMelodic IntonationIntelligibility DrillsOral Motor ExercisesPicture IdentificationFollowing Directions 2 2 2 2 2 2 2Setting Table

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Advancing the exercises Cognitive Exercises

STROOP• Increase # of stimuli• Performed while standing on thin

piece of foam Alphabetizing

• Increase Alpha difficulty• Performed while sitting on

physioball Sorting

• Increase difficulty level of stimuli• Performed while tandem standing

Sequencing• Increase difficulty level of stimuli• Increased reach distance from base

of support Selective & Divided Attention

• Increased time on task• Increased # of distracting variables

Cognitive Exercises Visual Attention

• Increase difficulty level of visual stimuli by adding variables

• Performed with increased base of support reaching modification

Memory• Increased amount of

information to retain• Added multiple auditory

distractors during memory task. Yes/No Questions

• Performed activity well in all settings. Discontinued after initial trial.

Following Directions• Increased # of directions• Added in-motion trigger for

obstacle course activity.

Case Study: OutcomesExercise Pre-LFA Post LFA Ms

ImprovementBoth Hands 166 ms 35 ms 131Right Hand 201 ms 37 ms 164Left Hand 160 ms 36 ms 124Both Toes 229 ms 82 ms 147Right Toe 183 ms 81 ms 102Left Toe 231 ms 85 ms 146Both Heels 305 ms 91 ms 214Right Heel 255 ms 79 ms 176Left Heel 244 ms 77 ms 167R Hand / L Toe 207 ms 89 ms 118L Hand / R Toe 234 ms 90 ms 144Balance R Foot Unable 101 ms *Balance L Foot Unable 121 ms *Both Hands-GDE

252 ms 32 ms 220

Case Study: Outcomes

TestIntake Patient Score

At High Risk for

Falling if:

Discharge Patient Score

TUG alone: 11 seconds > 14 seconds 9 seconds

TUG Cognitive: 16 seconds > 14.5

seconds 13 seconds

TUG Manual: 18 seconds > 15

seconds 13 seconds

(Shumway-Cook, Brauer, & Woollacott, 2000)

Case Study: ST OutcomesSubtests from the Ross Information Processing

Assessment-Geriatric (RIPA-G), were administered to assess memory and processing skills.

* Within Normal Limits

Subtest Intake Severity Rating

Discharge Severity Rating

Immediate Memory Moderate Mild

Recent Memory Mild WNL

Temporal Orientation Moderate WNL

Spatial Orientation Moderate MildOrientation to Environment Mild WNL

Recall of General Info WNL* WNLProblem Solving and Reasoning Mild WNL

Case Study: ST Outcomes

Subtests from the Ross Information Processing Assessment-Geriatric (RIPA-G), were administered to assess memory and processing skills.

Subtest Intake Severity Rating

Discharge Severity Rating

Organization of Information Moderate Mild

Auditory Processing and Comprehension

Mild WNL

Problem Solving and Concrete Reasoning

WNL WNL

Naming Common Objects WNL WNL

Functional Oral Reading WNL WNL

Determining when to Discharge

Reassessed using standardized testing

Goals and objectives metFamily support in placeAccess to Silver Sneakers Program

including transportation to and from and finances to cover

Home Exercise Planning

Recommend 3x’s a week atSilver Sneaker Program

HEP for discipline specific (Physical and Speech Therapy) activities to continue with caregiver support at least 2x’s a week

Post-test

Complete post-test for Module 6

Materials Page

This videoPowerPointCase Study Worksheets

www.interactivemetronome.com/index.php/fall-risk-coaching

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