2010 sure step
TRANSCRIPT
A Multi-Factorial Falls Intervention
An Evidence Based Prevention Program
Sunday, April 15, 12
Session 20October 23, 2010
Concordia University WisconsinMequon, WI
2010 WOTA CONFERENCE
Sunday, April 15, 12
Sandra Ceranski, MS, OTR/L
Carol Dickert, MS, OTR/L, LPTA
Carol Pociecha-Palm, MRE, OTR/L
Sunday, April 15, 12
LEARNING OBJECTIVES
• Discuss the theoretical base of Sure Step as a multi-factorial falls intervention.
• Discuss background and main elements of the Sure Step algorithm.
• Practice administration, scoring and interpretation of selected screens
• Discuss the clinical application and reimbursement perspectives in participant’s practice settings.
© Sandra Ceranski, MS, OTR
Sunday, April 15, 12
• Multi-factorial falls intervention developed 2001
• Jane Mahoney, MD and Terry Shea, PT
• Adapted from evidence based guidelines published by AGS, BMS and AAOS
SURE STEP IS...
© Sandra Ceranski, MS, OTR
Sunday, April 15, 12
SURE STEP INCLUDES
• In home fall risk assessment using detailed algorithm
• Follow-up in home visit with recommendations
• Referrals and recommendations for client, Physician/Primary Care and Therapists
• Monthly phone contacts for 12 months© Sandra Ceranski, MS, OTR
Sunday, April 15, 12
ALGORITHM
“A step-by-step procedure for solving a problem”
(Merriam-Webster online)
© Sandra Ceranski, MS, OTR
Sunday, April 15, 12
• 25 risk factor “areas” to measure through screening/assessment processes
• Medication, risky behavior, environment, vision, cognition, balance, gait and other factors
• Triggers based on measures WFL or not WFL
• Recommended “Action to Take”
• Recommendations for “Health Professionals”
ALGORITHM
© Sandra Ceranski, MS, OTR
Sunday, April 15, 12
STEP BY STEP PROBLEM SOLVINGRisk Factor Area Triggers Action to Take &
Recommendations
• Medications/OTC
• Benzodiazpenes
• Sleepers
• Antidepressants
• Neuroleptics
• Allergy Med
• Use of medication
• Class
• Education on risk
• Alternatives
• Discuss with MD
• ↓ dose as able
• Avoid
© Sandra Ceranski, MS, OTR
Sunday, April 15, 12
Mahoney, et al. 2005
POTENTIAL COST SAVINGSNursing
Home Costs$176/day was cost of NH in WI in 2004
Cost savings from reduced NH stay by 50 days = $8,800/person
HospitalStays
$15,000 avg. cost of older adult in WI 2002$15,000 cost savings by averting one hospitalization per year
Cost of Fall The average cost of a prevented fall has been estimated at $1,900
Effective select
45 % fewer falls for person with MMSE <28 with live in caregiver
Sunday, April 15, 12
POSTURAL STABILITY
A fall, or not falling, is not an event...it’s a process
© Carol Dickert, MS, OTR, PTA
Sunday, April 15, 12
PROCESS INVOLVES 3 COMPONENTS
• Sensory Input
• Central Processing
• Effector Output
© Carol Dickert, MS, OTR, PTA
Sunday, April 15, 12
COMPONENTS OF POSTURAL CONTROL
©2006 Sure Step Training Manual Mahoney, Shea, Schwalbe, Cech
Musculoskeletal
Strength
Biomechanical
Effector Output
Cognition
CNS Pathways
Medications
Central Processing
Visual
Vestibular
Proprioceptive
Sensory Input
Environment
Sunday, April 15, 12
SENSORY INPUT
“Our Sensory Systems take in Information from the environment regarding our body’s position in space, then sends that information to the Central Nervous
System (the Spinal Cord and Brain).”
© Carol Dickert, MS, OTR, PTA
Sunday, April 15, 12
CENTRAL PROCESSING
The brain takes the information that is received from the Sensory Input...processes that information...and
determines an appropriate response.
© Carol Dickert, MS, OTR, PTA
Sunday, April 15, 12
EFFECTOR OUTPUT
Nerves carry information regarding the appropriate response from the brain to the muscles & joints. The muscles respond by making changes/responses that
sustain balance & equilibrium for the Body.
© Carol Dickert, MS, OTR, PTA
Sunday, April 15, 12
WHAT CAN GO WRONG?
© Carol Dickert, MS, OTR, PTA
Sunday, April 15, 12
SENSORY INPUT
VISION
© Carol Dickert, MS, OTR, PTA
Sunday, April 15, 12
VISION
As we age our Visual Acuity changes.We need more time to adjust to darkness. Young adults
can adjust to the dark almost instantaneously. Older adults require up to 15-20 minutes for the eyes to adjust
to the dark
© Carol Dickert, MS, OTR, PTA
Sunday, April 15, 12
VISION
Depth Perception - Significantly different visual ability in the eyes will cause unsafe depth
perception. Problems with depth perception cause falls risk, especially on stairs.
© Carol Dickert, MS, OTR, PTA
Sunday, April 15, 12
VISION
Multifocal Lenses - Bifocals or Trifocals. Progressive lenses impair depth perception on stairs if you don’t
look through the correct level in the lense. This problematic if the person cannot perform adequate
cervical flexion due to limited ROM/Pain.
© Carol Dickert, MS, OTR, PTA
Sunday, April 15, 12
SENSORY INPUT
VESTIBULAR SYSTEM
© Carol Dickert, MS, OTR, PTA
Sunday, April 15, 12
VESTIBULAR SYSTEM
The inner ear allows a person to sense motion & the position of
the head in space.
© Carol Dickert, MS, OTR, PTA
Sunday, April 15, 12
DISORDERS OF THE VESTIBULAR SYSTEM
•Meniere’s Disease
• Labyrinthitis
• Benign Positional Vertigo
• Ear Infections
•Tumors
•Trauma
© Carol Dickert, MS, OTR, PTA
Sunday, April 15, 12
VESTIBULAR PROBLEMS MAY BE WORSE
• in crowded areas
• when turning the head
• in the dark
• rocking, spinning and/or up-down movement
© Carol Dickert, MS, OTR, PTA
Sunday, April 15, 12
SENSORY SYSTEM
PROPRIOCEPTION
© Carol Dickert, MS, OTR, PTA
Sunday, April 15, 12
PROPRIOCEPTION
The Somatosensory System consists of motion, position & pressure sensors in the joints, muscles & skin. These
sensors provide tactile & positional information to enable us to sustain postural control/balance.
© Carol Dickert, MS, OTR, PTA
Sunday, April 15, 12
CAUSES OF PROPRIOCEPTIVE PROBLEMS
• Peripheral Neuropathy
• Loss of Vibratory Sense
• Loss of Light Touch & Joint Position Sense
© Carol Dickert, MS, OTR, PTA
Sunday, April 15, 12
COGNITION
CENTRAL PROCESSING
© Carol Dickert, MS, OTR, PTA
Sunday, April 15, 12
COGNITION
• As cognition declines, the incidence of falls increases. There is a direct correlation between decreased cognitive abilities and increased falls & injury.
• The higher levels of cognition – executive functions are key in the patient’s abilities in safety judgment/ safety awareness.
• As executive function declines, patients engage in more risk behaviors during their ADLs/ IADLs/ MRADLs.
© Carol Dickert, MS, OTR, PTA
Sunday, April 15, 12
CENTRAL NERVOUS SYSTEM PATHWAYS
© Carol Dickert, MS, OTR, PTA
Sunday, April 15, 12
DISEASE THAT IMPEDE CNS PATHWAYS
• Cerebrovascular Accident
• Brain infections or abscesses
• Multiple Sclerosis
• Parkinsons Disease
• Degenerative Syndromes (i.e. alcoholism)
• Depression (↓attention to the environment, slowed cognitive & motor reactions)
• Head Trauma
• Heart conditions (i.e. CHF, Abnormal Rhythms, ↓Blood flow to the brain)
© Carol Dickert, MS, OTR, PTA
Sunday, April 15, 12
MEDICATIONS
Psychotropic medications affect balance because they decrease alertness to the environment and
slow the rate of central processing.
© Carol Dickert, MS, OTR, PTA
Sunday, April 15, 12
MEDICATIONS
When a young adult takes a medication, half of that medication remains in their body 1 day later. When an older adult takes a medication, half is in their body 1
WEEK later. This causes a significant cumulative effect.
© Carol Dickert, MS, OTR, PTA
Sunday, April 15, 12
EFFECTOR OUTPUT
© Carol Dickert, MS, OTR, PTA
Sunday, April 15, 12
MUSCULOSKELETAL
Unsafe Balance/ Stability - The Sure Step Program administers
several balance & gait tests.
© Carol Dickert, MS, OTR, PTA
Sunday, April 15, 12
INADEQUATE EQUILIBRIUM AND
RIGHTING REACTION
© Carol Dickert, MS, OTR, PTA
Sunday, April 15, 12
EQUILIBRIUM
The body’s ability to sustain the center of gravity at midline
© Carol Dickert, MS, OTR, PTA
Sunday, April 15, 12
The body’s ability to return the center of gravity to midline/ right itself when displaced beyond its
limits of stability.
RIGHTING REACTIONS
© Carol Dickert, MS, OTR, PTA
Sunday, April 15, 12
INADEQUATE EQUILIBRIUM AND RIGHTING REACTIONS
• Tripping Falls
• Slipping Falls
• Reaching (Center of Mass) Falls
© Carol Dickert, MS, OTR, PTA
Sunday, April 15, 12
LIMITS OF STABILITY
© Carol Dickert, MS, OTR, PTA
• “Limits of Stability” is how far the body can sway without taking a step.
• Moving the Center of Gravity beyond these limits may cause falls during ADLs/ IADLs/ MRADLs.
Sunday, April 15, 12
• 8° Forward
• 4° Backward
• 8° Laterally Left & Right
© Carol Dickert, MS, OTR, PTA
LIMITS OF STABILITY
Sunday, April 15, 12
STRENGTH
• Decreased hand strength is one indicator of increased risk for falls.
• Lower extremity strength is essential in preventing falls. All mobility skills (sit to stand, transfers, ambulation, stair climbing, etc.) require adequate LE strength.
© Carol Dickert, MS, OTR, PTA
Sunday, April 15, 12
BIOMECHANICAL
• Improper footwear is a fall risk.
• In general the best is a firm, thin soled shoe with good support and good tread on the bottom.
• Slippers, stocking feet, and bare feet should be avoided.
© Carol Dickert, MS, OTR, PTA
Sunday, April 15, 12
FOOT DEFORMITIES
• Tendonitis
• Plantar Fasciitis
• Heel Spurs
© Carol Dickert, MS, OTR, PTA
Sunday, April 15, 12
ABNORMAL GAIT PATTERNS• Decreased Step Height & Length
during Gait Cycle
• Asymmetrical Gait (Example: “stiff” hip/ knee w/ hiking to clear floor)
• Lack of Continuity during Gait
• Antalgic (Painful) Gait Pattern
• Trendelenberg (Gluteus Medius) Gait Pattern
• Hemiplegic Gait Pattern
• Parkinsonian Gait Pattern
• Scissors Gait Pattern (due to Spastic Hip Adductors)
• Foot Drop Gait w/ ↓Ability to Dorsiflex the Ankle
© Carol Dickert, MS, OTR, PTA
Sunday, April 15, 12
Sure Step Algorithm©2006 Sure Step Training Manual Mahoney, Shea, Schwalbe, Cech
Sunday, April 15, 12
Measurement Areas to distinguish
Action to Take &Recommendations
2 or more falls in year prior1 fall & history of near falls or imbalanceAcute infection related to falls (UTI, pneumonia, etc.)Medical conditions: Stroke, LE arthritis, LE fractures & Neuropathy
If ≥ fall risk factor
Educate patient and caregiver regarding # risk factors means greater riskCaution ill or med. changesEnvironmental changesUse assistive deviceNotify Physician
FALL RISK FACTORS
© Carol Pociecha-Palm, OTR
Sunday, April 15, 12
Measurement Areas to distinguish
Action to Take &Recommendations
Current Assistive Equipment
CURRENT ASSISTIVE EQUIPMENT
© Carol Pociecha-Palm, OTR
Sunday, April 15, 12
Measurement Areas to distinguish
Action to Take &Recommendations
Residence:
Senior apartmentApartment (not senior housing)
Live alone or with someone (describe)
RESIDENCE
© Carol Pociecha-Palm, OTR
Sunday, April 15, 12
Measurement Areas to distinguish
from measurement
Action to Take &Recommendations
Fall History
1. ______________________
2. ______________________
3._______________________
If Fall Ask patient to discuss with physicianEducate patient and cargiverTripping/slipping fallsFalls with movementFalls with rising
FALL HISTORY
© Carol Pociecha-Palm, OTR
Sunday, April 15, 12
Measurement Areas to distinguish
Action to Take &Recommendations
“How confident are you that you can do___without falling?” (LC, FC...) Risky: Y; N
Meal PrepShoppingBathingWalking on snow and ice
Any potentially risky IADL/ADL
Any non-risky IADL/ADL with “Not at all confident”
EducationTask specific modifications:
increased supervisionhome modificationtask avoidancemeals on wheels
IADL’S, MOBILITY ADL’S AND CONFIDENCE
© Carol Pociecha-Palm, OTR
Sunday, April 15, 12
Measurement Areas to distinguish
Action to Take &Recommendations
PetsPoor day or night lightingNocturiaBifocals, trifocals, progressive lenses
If patient does any behavior
Recommend OT for modifying behavior & techniques with ADL’s/IADL’sNocturia (decrease evening water intake, no caffeine after 5:00 pm
RISKY BEHAVIORS
© Carol Pociecha-Palm, OTR
Sunday, April 15, 12
Measurement Areas to distinguish
Action to Take &Recommendations
What type(s) of physical activity do you get?
Describe amount & type:
TYPE OF PHYSICAL ACTIVITY
© Carol Pociecha-Palm, OTR
Sunday, April 15, 12
Measurement Areas to distinguish
Action to Take &Recommendations
Do you have any pain with walking, doing exercises, or performing normal activities?Rate pain 0-10 _____Describe:
Current treatment for pain?
Past treatment for pain?
If yes Ask patient to discuss with physicianRecommend PT/OT for pain managementDiscuss and encourage types of exercise that patient is already doing to alleviate pain
PAIN
© Carol Pociecha-Palm, OTR
Sunday, April 15, 12
Measurement Areas to distinquish
Action to Take &Recommendations
During the past month, have you often been bothered by:
1. Little interest or pleasure in doing things?
2. Feeling down, depressed or hopeless?
If > Yes to 1 or 2 Advise patient to discuss with MD, as it slows recovery and raises fall risk.
Notify MD-phone call is warranted if patient answered “yes” to both questions #1 and #2 on the Two-Question Depression Scale.
Two-Question Depression Screen
© Carol Pociecha-Palm, OTR
Sunday, April 15, 12
Measurement Triggers Action to Take &Recommendations
VAMC SLIMS ExaminationWhat is the highest level of education completed?
High School Education?Less than High School?
If score < 27 and has high school education
or < 25 if less than high school education
Discuss with patient and caregiver regarding raised fall risk, need for supervision, etc.Need for supervisionConsider further evaluation for cognitive impairment and treatment as appropriateConsider evaluation for reversible causes of cognitive impairment B-12 etc.
VAMC SLUMS
© Carol Pociecha-Palm, OTR
Sunday, April 15, 12
Sunday, April 15, 12
Measurement Areas to distinguish
Action to Take &Recommendations
Vitamins and Diet1.Calcium (Supplement & Diet)2.Vitamin D3.Multivitamin4.When was your last Bone Mineral Density Test?
If Calcium < 1200 mg/day
If Vitamin D < 800 iu/day
Recommend daily elemental calcium intake of 1200 mg/dayRecommend 1 multivitamin per dayRecommend daily intake of 800-1000 iu Vitamin d per day as recommended in 2008.
VITAMINS AND DIET
© Carol Pociecha-Palm, OTR
Sunday, April 15, 12
MEDICATIONRisk Factor Area Triggers Action to Take &
Recommendations
• Sleep Medication
• Antidepressants
• Anxiety
• Antipsychotic
• Allergy Med/spray
• Dizziness
• Neuropathic pain
• Bladder control
• Alcohol use
• Use
• Dose
• Class
• Educate on risk
• Avoid or minimize
• Lowest does
• Alternatives
• Discuss with MD
© Sandra Ceranski, MS, OTR
Sunday, April 15, 12
VISIONRisk Factor Area Triggers Action to Take &
Recommendations
• Eye Exam
• Type of lenses
• Use with walking
• Vision test
• Visual field
• <20/40
• Difference between eyes
• No visit in past year
• Multi-focal lenses
• Good lighting
• Environment
• Mobility device
• Caution stairs, curbs
• See eye doctor
• Refer Vision & OT
• Single vision lenses
• Cataract surgery
© Sandra Ceranski, MS, OTR
Sunday, April 15, 12
FOOT DEFORMITYRisk Factor Area Triggers Action to Take &
Recommendations
• Observe with shoes off
• Hammer toes
• Bunions
• Abnormal • Refer to podiatrist for balance and gait
• Extra depth shoes
• Ankle foot orthotics
© Sandra Ceranski, MS, OTR
Sunday, April 15, 12
ANKLE ALIGNMENTRisk Factor Area Triggers Action to Take &
Recommendations• Observe during standing and
walking with shoes on and off• Not corrected
with shoes on• Refer to Podiatrist or PT
© Sandra Ceranski, MS, OTR
Sunday, April 15, 12
FOOTWEARRisk Factor Area Triggers Action to Take &
Recommendations
• High heels
• Floppy slippers
• > 1 in. heels/soles
• Large tread
• Yes to any • Avoid
• Firm thin soles
• Podiatrist
© Sandra Ceranski, MS, OTRSunday, April 15, 12
VIBRATIONRisk Factor Area Triggers Action to Take &
Recommendations
• Lie down
• 128 Hz tuning fork
• Toe and ankle with eyes closed
• If absent • Education
• Cane or AD
• Extra caution
• Diagnosis
© Sandra Ceranski, MS, OTR
Sunday, April 15, 12
ORTHOSTASIS
• A patient with Orthostatic Hypotension may experience Syncope (pass out), or may fall due to Orthostatic Hypotension without fainting.
• To measure, use Blood Pressure Cuff & Stethoscope to get Blood Pressure reading. Record Pulse Rate.
© Carol Dickert, MS, OTR, PTA
Sunday, April 15, 12
ORTHOSTASIS
• “Normal” Blood Pressure is 120/80. “Normal” Pulse Rate is 60 beats/ minute.
• Record Blood Pressure & Pulse Rate after patient lies supine for 3-5 minutes. Then standing position for 1 minute. If the Systolic (Top) number drops by >20 points, Orthostasis is problematic.
© Carol Dickert, MS, OTR, PTA
Sunday, April 15, 12
ORTHOSTASIS
Alert the Physician:
" Systolic reading is too high >180
" Systolic reading is too low <100
" Diastolic reading is too high >90
© Carol Dickert, MS, OTR, PTA
Sunday, April 15, 12
SURE STEP ALGORITHM
• Let’s learn by doing
•What do you want to learn more about?
•What could you incorporate into your practice?
© Sandra Ceranski, MS, OTR
Sunday, April 15, 12