beyond balance: evidence based practice enhancing quality of life in the geriatric patient
DESCRIPTION
Beyond Balance: Evidence Based Practice Enhancing Quality of Life in the Geriatric Patient. Jenny Zimney, MPT, GCS [email protected] Northwest Rehabilitation Associates 1380 Liberty St. SE Salem, OR 97302 (503) 371-0779. Beyond Balance: . What factors create safety and balance? - PowerPoint PPT PresentationTRANSCRIPT
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Beyond Balance:Beyond Balance: Evidence Based Practice Enhancing Quali Evidence Based Practice Enhancing Quality of Life in the Geriatric Patientty of Life in the Geriatric Patient
Jenny Zimney, MPT, GCSJenny Zimney, MPT, GCS
[email protected]@northwestrehab.com
Northwest Rehabilitation AssociatesNorthwest Rehabilitation Associates1380 Liberty St. SE1380 Liberty St. SESalem, OR 97302Salem, OR 97302(503) 371-0779(503) 371-0779
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Beyond Balance: Beyond Balance: What factors What factors
create safety and create safety and balance?balance?
Can I really Can I really impact the impact the frequent faller?frequent faller?
Can fear of falling Can fear of falling be overcome?be overcome?
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Course Objectives:Course Objectives:Following today’s session you will be able to:Following today’s session you will be able to:1.1. Choose and implement the appropriate Choose and implement the appropriate
functional scale for their patient status and functional scale for their patient status and setting. setting.
2.2. Develop objective measurable treatment Develop objective measurable treatment interventions and goals based on the functional interventions and goals based on the functional scales used. scales used.
3.3. Discuss the rationale and purpose for each Discuss the rationale and purpose for each functional scale presented. functional scale presented.
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Course Objectives cont’d:Course Objectives cont’d:4.4. Quantify a geriatric patients balance, Quantify a geriatric patients balance,
fear of falling and fall risk using the fear of falling and fall risk using the functional scales presented. functional scales presented.
5.5. Identify reliable reimbursement and Identify reliable reimbursement and marketing options for fall prevention marketing options for fall prevention programs in your community. programs in your community.
6.6. Make a greater impact on reducing falls Make a greater impact on reducing falls in your community!in your community!
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Systems of BalanceSystems of Balance
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Balance and Motor Planning:Balance and Motor Planning: What is my plan/objective?What is my plan/objective? What am I feeling?What am I feeling? What am I going to do about it?What am I going to do about it? Was this successful last time?Was this successful last time? What is my plan this time?What is my plan this time? Can my body do this (or) do this in Can my body do this (or) do this in
time?time?
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Allum et al 2002 J PhysAllum et al 2002 J PhysChanges in Postural Control with AgeChanges in Postural Control with AgeResults:Results:
With perturbation on sway boardWith perturbation on sway boardYounger = Trunk rolls toward Younger = Trunk rolls toward from from perturbation (uphill)perturbation (uphill)
Older = Trunk rolls away from Older = Trunk rolls away from perturbation (downhill)perturbation (downhill)
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Sensory SystemsSensory SystemsVision
VestibularVestibularSomatosensorSomatosensoryy
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Age Related Changes: Age Related Changes: VisionVision
↓↓ visual acuityvisual acuity Impaired dark adaptationImpaired dark adaptation ↓ ↓ response to peripheral field visual response to peripheral field visual
stimulistimuli ↓↓ contrast sensitivitycontrast sensitivity Difficulties with accommodationDifficulties with accommodation Abnormal visual perceptionAbnormal visual perception
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Age Related Changes: Age Related Changes: VestibularVestibular
Loss of hair cells in semicircular Loss of hair cells in semicircular canalscanals
Calcification in cupulaCalcification in cupula
““Thinning” of vestibular afferent Thinning” of vestibular afferent axonsaxons
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Age-Related Changes: Age-Related Changes: SomatosensorySomatosensory
10-15% 10-15% ↓↓ nerve conduction velocity nerve conduction velocity
↑ ↑ Sensory detection thresholdsSensory detection thresholds
↑↑ Central processing timeCentral processing time
↑ ↑ latency of automatic postural responseslatency of automatic postural responses
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Age related changes: Age related changes: Efferent SystemEfferent System
↑ ↑ Active muscle stiffnessActive muscle stiffness ↓ ↓ Muscle force and power generation Muscle force and power generation
capacitycapacity ↑ ↑ Variability of contraction amplitudes Variability of contraction amplitudes
for proximal/distal muscles of a for proximal/distal muscles of a synergysynergy
↑ ↑ of trials to adapt strategy for of trials to adapt strategy for perturbationperturbation
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Age Related Changes: Age Related Changes: EtiologyEtiology
Normal changes associated w/ agingNormal changes associated w/ aging Decrease in physical Decrease in physical
activity/stimulationactivity/stimulation Disease states: Diabetes, PVD, CVA, Disease states: Diabetes, PVD, CVA,
vestibular dysfunctions, macular vestibular dysfunctions, macular degenerationdegeneration
ORORLearned non-useLearned non-use
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TaskRequirements
AmbientConditions
Medications
Somatosensory
ROMHx of
Balance ReactionsTemporal
FactorsPhysical
Load
Comorbidities
MuscularPower/
Endurance
Attention/Cognition
Vestibular
EnvironmentalTerrain
ReactionTime
Vision
The EquilibriumOf
Balance
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Common medications related Common medications related to falls:to falls:
Benzodiazapines (Valium, Ativan)Benzodiazapines (Valium, Ativan) Sedatives (Benadryl, Buspar)Sedatives (Benadryl, Buspar) Hypnotics (Xanax)Hypnotics (Xanax) Antipsychotics (Thorazine, Haldol)Antipsychotics (Thorazine, Haldol) Antidepressants (Elavil)Antidepressants (Elavil) Antihypertensives (Lopressor, Catapress)Antihypertensives (Lopressor, Catapress) Antianxiety (Librium)Antianxiety (Librium) Diuretics (Lasix, Diuril)Diuretics (Lasix, Diuril)
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Balance Review: More Balance Review: More thoughts…thoughts…
Environmental DemandsEnvironmental Demands
Cognition/Attentional Demands Cognition/Attentional Demands
Self-Efficacy/Fear of FallingSelf-Efficacy/Fear of Falling
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Environmental Demands and Environmental Demands and Balance/MobilityBalance/Mobility
36 older adults self reported trip log and 36 older adults self reported trip log and videotaped weekly (tracking 8 environ videotaped weekly (tracking 8 environ
dimensions) dimensions) Results: Temporal (speed), physical Results: Temporal (speed), physical
load, terrain and postural transitions load, terrain and postural transitions (head mvmt) distinguished those w/ (head mvmt) distinguished those w/ disabilities, 1/2 as many activities disabilities, 1/2 as many activities and had to be accompanied.and had to be accompanied.
(Shumway-Cook A, et al. Phys Ther. 2002;82:670-681)(Shumway-Cook A, et al. Phys Ther. 2002;82:670-681)
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Attentional Demands:Attentional Demands:Static vs. Dynamic EquilibriumStatic vs. Dynamic Equilibrium6 healthy young subjects (20-30 yo)6 healthy young subjects (20-30 yo)Tested reaction time to auditory cue with Tested reaction time to auditory cue with
sitting, standing upright (broad and narrow sitting, standing upright (broad and narrow base, walking (SLS and DLS)base, walking (SLS and DLS)
Standing > sitting; Walking > sit or stand; Standing > sitting; Walking > sit or stand; SLS > DLSSLS > DLS
Conclusion: Balance control w/in gait is not Conclusion: Balance control w/in gait is not automatic.automatic.
Lojoie, Teasdale, Bard, Fleury. Exp Brain Res. 1993;97:139-144.Lojoie, Teasdale, Bard, Fleury. Exp Brain Res. 1993;97:139-144.
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Attentional Demands of Attentional Demands of Obstacle NegotitationObstacle Negotitation
15 older adults vs. 15 younger adults15 older adults vs. 15 younger adults Testing reaction time to auditory cue Testing reaction time to auditory cue
with walking level and over foam with walking level and over foam block when in SLSblock when in SLS
Results: Pre-crossing and Crossing Results: Pre-crossing and Crossing were = in older adults were = in older adults
Brown, McKenzie, Doan. J Geron. 2005;60A(7):924-927Brown, McKenzie, Doan. J Geron. 2005;60A(7):924-927
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Attentional Demands:Attentional Demands:Dual-task Methodology:Dual-task Methodology:1.1. Limited Central Processing CapacityLimited Central Processing Capacity2.2. Task performance requires part the Task performance requires part the
limited capacity within the CNSlimited capacity within the CNS3.3. If performing 2 tasks and that If performing 2 tasks and that
capacity is exceeded, 1 or both capacity is exceeded, 1 or both tasks can be disturbed.tasks can be disturbed.
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Voluntary Step and Cognitive Voluntary Step and Cognitive TaskTask
66 healthy elderly vs. healthy young adults66 healthy elderly vs. healthy young adults Tested voluntary stepping on force plate Tested voluntary stepping on force plate
single task and w/ modified Stroop testsingle task and w/ modified Stroop testResults: Older adults withResults: Older adults withSingle task: 42-52% slower step initiationSingle task: 42-52% slower step initiationDual task: 190-256% slower, 41% no reaction Dual task: 190-256% slower, 41% no reaction Melzer, Oddsson. JAGS. 2004;58(8):1255-1262Melzer, Oddsson. JAGS. 2004;58(8):1255-1262
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Fear of Falling Influences Fear of Falling Influences GaitGait
95 com-dwell older adults95 com-dwell older adults Gait parameters: speed, stride length, Gait parameters: speed, stride length,
step width, double limb support timestep width, double limb support time In fearful group, speed was slower, stride In fearful group, speed was slower, stride
shorter, step width larger and double shorter, step width larger and double limb support time was 6% longer.limb support time was 6% longer.
Chamberlin ME, Fulwider BD, Sanders SL, Medeiros JM. J Geron: Med Sci. 2005;60A:9:1163-1167Chamberlin ME, Fulwider BD, Sanders SL, Medeiros JM. J Geron: Med Sci. 2005;60A:9:1163-1167
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Fear of Falling: Fear of Falling: Predisposing FactorsPredisposing Factors
6. No Emotional Support6. No Emotional Support5. Sedentary Lifestyle 5. Sedentary Lifestyle 4. Chronic Dizziness4. Chronic Dizziness3. Fall history w/ in previous year3. Fall history w/ in previous year2. Vision > 50% impaired2. Vision > 50% impaired1: Age > 80 Anxiety Trait 1: Age > 80 Anxiety Trait Murphy, Dubin, Gill. J Geron 2003;58A(10):M943-947.Murphy, Dubin, Gill. J Geron 2003;58A(10):M943-947.
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Assessing Balance: Falls Assessing Balance: Falls HistoryHistory
How often do you lose your balance, How often do you lose your balance, i.e. slip, trip or stumble?i.e. slip, trip or stumble?
When was your most recent fall?When was your most recent fall? Did the fall occur inside or outside?Did the fall occur inside or outside? How did the fall occur?How did the fall occur? Were you injured?Were you injured? Were you dizzy when you fell?Were you dizzy when you fell?
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Why use Functional Testing?Why use Functional Testing? Evidence-basedEvidence-based Demonstrate skillDemonstrate skill Establish GoalsEstablish Goals Guide to treatmentGuide to treatment Objective measure Objective measure
of progressof progress Prediction of future Prediction of future
eventsevents
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Types of ReportingTypes of Reporting Self-Report**Self-Report** Clinician observation Clinician observation
and rating**and rating** Equipment-based Equipment-based
testingtesting
**Focus of Functional Test presented**Focus of Functional Test presented
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Which is best?Which is best?
Self-Report
Clinical Observation
Proxy-Report
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The Activities-specific Balance The Activities-specific Balance Confidence Scale (ABC)Confidence Scale (ABC)
Developed by Powell and Myers with input from Developed by Powell and Myers with input from 15 clinicians and 12 older outpatients to 15 clinicians and 12 older outpatients to quantify fear of falling quantify fear of falling
Type of Information:Type of Information: Self Report Self Report
Components:Components: 16 items of varying difficulty 16 items of varying difficulty rated on 0-100% scalerated on 0-100% scale Equipment needed:Equipment needed: Paper and pencil Paper and pencil
Time to Complete Test:Time to Complete Test: 5-10 minutes 5-10 minutes
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The Activities-specific Balance The Activities-specific Balance Confidence Scale (ABC)Confidence Scale (ABC)
Scoring:Scoring:> 80 = high functioning > 80 = high functioning older adult (I com. older adult (I com. Dwelling)Dwelling)50-80 = moderate level of 50-80 = moderate level of functioning (Chronic Health functioning (Chronic Health Conditions or ALF)Conditions or ALF)< 50 = low physical < 50 = low physical functioning (Home care)functioning (Home care)
Myers AM et al, Myers AM et al, J of Gerontol:Medical Sci, 1998J of Gerontol:Medical Sci, 1998
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The Activities-specific Balance The Activities-specific Balance Confidence Scale (ABC)Confidence Scale (ABC)
Strengths:Strengths: InexpensiveInexpensive Self TestingSelf Testing Examines Examines
community mobilitycommunity mobility Variety of situations Variety of situations
and environments and environments assists in treatment assists in treatment and goal settingand goal setting
Weaknesses:Weaknesses: Cannot use w/ Cannot use w/
significant cognitive significant cognitive impairmentimpairment
Imagination needed Imagination needed if not regularly if not regularly performedperformed
Very high ceilingVery high ceiling Nearly no floor Nearly no floor
effectseffects
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Modified Falls Efficacy Scale Modified Falls Efficacy Scale (mFES)(mFES)
Adapted from Tinetti’s FES to quantify fear of Adapted from Tinetti’s FES to quantify fear of falling falling
Type of Information:Type of Information: Self Report Self Report
Components:Components: 16 items of varying difficulty 16 items of varying difficulty rated on 0-100% rated on 0-100%
scalescale Equipment needed:Equipment needed: Paper and pencil Paper and pencil
Time to Complete Test:Time to Complete Test: 5-10 minutes 5-10 minutes
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Modified Falls Efficacy Scale Modified Falls Efficacy Scale (mFES)(mFES)
Scoring:Scoring:Items are scored from 0 to 10.Items are scored from 0 to 10.Total the ratings (possible range = 0 Total the ratings (possible range = 0 – 140) and divide by 14 to get each – 140) and divide by 14 to get each subject’s mFES score. subject’s mFES score. Scores of < 8 indicate fear of falling, Scores of < 8 indicate fear of falling, 8 or greater indicate lack of fear.8 or greater indicate lack of fear.
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Modified Falls Efficacy Scale Modified Falls Efficacy Scale (mFES)(mFES)
Strengths:Strengths: InexpensiveInexpensive Self TestingSelf Testing Assesses indoor and Assesses indoor and
outdoor situationsoutdoor situations More realistic More realistic
activities then ABCactivities then ABC
Weaknesses:Weaknesses: Cannot be used w/ Cannot be used w/ significant cognitive significant cognitive impairmentimpairment
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ABC mFESVS
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Timed “Up and Go”Timed “Up and Go”Developed by Richardson and Podsiadlo to Developed by Richardson and Podsiadlo to
assess basic mobility skills in older adults assess basic mobility skills in older adults Type of Information:Type of Information: Clinician Observation and Clinician Observation and ratingrating Components:Components: One Item- stand, walk 10 ft, turn One Item- stand, walk 10 ft, turn
come back and sit down.come back and sit down.
Equipment needed:Equipment needed: Stopwatch, Chair (46cm)w/ Stopwatch, Chair (46cm)w/ arms (65 cm)arms (65 cm)
Time to Complete Test:Time to Complete Test: 1-2 minutes 1-2 minutes
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Timed “Up and Go”Timed “Up and Go”Scoring:Scoring: >30 sec people that are more >30 sec people that are more
dependent, unable to climb stairs, dependent, unable to climb stairs, require AD, help with transfers, require AD, help with transfers, dependent in most activitiesdependent in most activities
<10 sec freely independent<10 sec freely independent <20 sec( I) transfers, I toilet, able to <20 sec( I) transfers, I toilet, able to
climb most stairs, go out alone climb most stairs, go out alone
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Timed “Up and Go”Timed “Up and Go”Strengths:Strengths: Can use assistive Can use assistive
devicedevice Quick, easy, Quick, easy,
inexpensiveinexpensive Incorporates most Incorporates most
aspects of mobilityaspects of mobility Sensitive to changeSensitive to change Not diagnosis Not diagnosis
dependentdependent
Weaknesses:Weaknesses: Not usable for non-Not usable for non-
ambulatory patientsambulatory patients Ceiling – not Ceiling – not
challenging for challenging for community dwellerscommunity dwellers
Must be able to Must be able to follow directionsfollow directions
Only a few aspects Only a few aspects of balance are of balance are challengedchallenged
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Normal Values of Balance Normal Values of Balance Tests in Women Aged 20-80Tests in Women Aged 20-80
456 women in 6 age cohorts456 women in 6 age cohortsTests: TUG, Step, FR, LRTests: TUG, Step, FR, LRResults: Results:
Linear change with Step and TUGLinear change with Step and TUGFR started to decline in 40’sFR started to decline in 40’sLR started to decline in 30’s!!!!!LR started to decline in 30’s!!!!!
Isles, Choy, Steer, Nitz JAGS 2004;52(8):1367-1372.Isles, Choy, Steer, Nitz JAGS 2004;52(8):1367-1372.
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Berg Balance ScaleBerg Balance ScaleDeveloped to measure balance of the older Developed to measure balance of the older
adult in a clinical settingadult in a clinical setting Type of Information: Clinician observation Clinician observation
Components: 14 items of everyday tasks 14 items of everyday tasks rated on 0-4 scalerated on 0-4 scale Equipment needed: Ruler, Watch, 2 Ruler, Watch, 2
standard chairs, footstool or step, objectstandard chairs, footstool or step, object Time to Complete Test: 15-20 minutes 15-20 minutes
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Berg Balance ScaleBerg Balance ScaleSpecifics of testing:Specifics of testing: No assistive device No assistive device
can be usedcan be used Must be able to Must be able to
stand unsupportedstand unsupported Forward reach w/ Forward reach w/
fingers fingers outstretched (36% outstretched (36% cannot do this)cannot do this)
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Berg Balance ScaleBerg Balance ScaleScoring:Scoring: 41-56 low fall risk41-56 low fall risk 21-40 medium fall risk21-40 medium fall risk 0-20 high fall risk0-20 high fall riskAdditionally Additionally > 45 safe, > 45 safe,
independent independent ambulatorambulator
< 36 fall risk near < 36 fall risk near 100%100%
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Berg Balance ScaleBerg Balance ScaleStrengths:Strengths: Challenging for Challenging for
healthy, Com. healthy, Com. DwellerDweller
Wide range of Wide range of difficulty and difficulty and patientspatients
Reliable for PD or Reliable for PD or CVACVA
Weaknesses:Weaknesses: Cannot use Cannot use
assistive deviceassistive device Ceiling effect for Ceiling effect for
high level high level functioningfunctioning
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Physical Performance TestPhysical Performance TestDeveloped to assess function in community dwelling Developed to assess function in community dwelling
older adultsolder adults Type of Information: Clinician observation and ratingClinician observation and rating Components: 3 Versions (7,8,9 item tests) rated on 3 Versions (7,8,9 item tests) rated on
0-4 scale0-4 scale Equipment needed: Stopwatch, paper & pen, bowl Stopwatch, paper & pen, bowl
and 5 kidney beans, spoon, coffee can, heavy and 5 kidney beans, spoon, coffee can, heavy book, jacket or sweater, penny, 25-foot walkway, book, jacket or sweater, penny, 25-foot walkway, flight of stairsflight of stairs
Time to Complete Test: 15-20 minutes 15-20 minutesReuben, Siu. JAGS 1990;38(10):1105-1112Reuben, Siu. JAGS 1990;38(10):1105-1112
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Physical Performance TestPhysical Performance TestSpecifics of testing:Specifics of testing: Timing is from the Timing is from the
word “Go”word “Go” Incorporates stair Incorporates stair
climbingclimbing
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Physical Performance TestPhysical Performance TestScoring:Scoring: < 15 predictor of < 15 predictor of
recurrent fallsrecurrent falls
**Treatments, goals **Treatments, goals and other referrals and other referrals can be designed can be designed from each item.from each item.
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Physical Performance TestPhysical Performance TestStrengths:Strengths: Can use assistive Can use assistive
devicedevice High ceilingHigh ceiling Measure multiple Measure multiple
areas of functionareas of function Responsive to Responsive to
change w/ change w/ functional trainingfunctional training
Weaknesses:Weaknesses: Requires equipmentRequires equipment Scale is ordinal- Scale is ordinal-
decreased decreased sensitivity to changesensitivity to change
May fail to challenge May fail to challenge multiple facets of multiple facets of balancebalance
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Physical Performance TestPhysical Performance Test Schmidt et al: Schmidt et al:
Predictive of frail elderly dropout rates Predictive of frail elderly dropout rates in exercise program in exercise program (JAGS 2000;48(8):952-960)(JAGS 2000;48(8):952-960)
Brown et al:Brown et al: Differentiates Mild to Moderate Frailty Differentiates Mild to Moderate Frailty
(J Geron 2000;55A(6):M350-(J Geron 2000;55A(6):M350-355.)355.)
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Dynamic Gait IndexDynamic Gait IndexDeveloped by Shumway-Cook and Wollacott to Developed by Shumway-Cook and Wollacott to
assess likelihood of falling in older adultsassess likelihood of falling in older adults Type of Information: Clinician observation and Clinician observation and
ratingrating Components: 8 facets of gait, 0-3 scale 8 facets of gait, 0-3 scale Equipment needed: box, 2 cones, stairs, at box, 2 cones, stairs, at
least 25 ft walkwayleast 25 ft walkway Time to Complete Test: 15 minutes 15 minutesShumway-Cook A, Woollacott A, Motor Control Theory and Practical Applications. Williams Shumway-Cook A, Woollacott A, Motor Control Theory and Practical Applications. Williams
& Wilkins, 1995& Wilkins, 1995
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Dynamic Gait IndexDynamic Gait Index
Specifics of the test:Specifics of the test: Test gait at different speedsTest gait at different speeds Stepping over and around Stepping over and around
obstaclesobstacles Gait w/ head turns (horizontal Gait w/ head turns (horizontal
and vertical)and vertical)
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Dynamic Gait IndexDynamic Gait Index
Scoring:Scoring:< 19 related to falls< 19 related to falls > 22 safe> 22 safe
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Dynamic Gait IndexDynamic Gait IndexStrengths:Strengths: Can use assistive Can use assistive
devicedevice Examines 8 Examines 8
facets of gait facets of gait including speed, including speed, head turns and head turns and over obstaclesover obstacles
Weaknesses:Weaknesses: Only looks at Only looks at
gaitgait Not tested in Not tested in
many many populationspopulations
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Whitney, Hudak, Marchetti Whitney, Hudak, Marchetti 20002000
Studied 247 patients with Studied 247 patients with vestibular disorders and found:vestibular disorders and found:
DGI effective to ID fall risk with DGI effective to ID fall risk with older and younger adults with older and younger adults with vestibular disordersvestibular disorders
J Vest Research 2000;10(2):99-105J Vest Research 2000;10(2):99-105
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Functional Gait Assessment
DGI
=
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Functional Gait Assessment Functional Gait Assessment (FGA)(FGA)
Developed by Wrisley et al. to increase Developed by Wrisley et al. to increase the sensitivity of DGI.the sensitivity of DGI.
Type of Information: Clinician observation Clinician observation and ratingand rating
Components: Equipment needed: 2 boxes, 2 cones, 2 boxes, 2 cones,
stairs, at least 25 ft walkway, stop stairs, at least 25 ft walkway, stop watchwatch
Time to Complete Test: 15 minutes 15 minutes
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Functional Gait Assessment Functional Gait Assessment (FGA)(FGA)
Strengths:Strengths: Can use assistive Can use assistive
devicedevice More sensitive to More sensitive to
change than DGIchange than DGI Walking backward Walking backward Dual-taskDual-task Environmental Environmental
barrierbarrier
Weaknesses:Weaknesses: Only looks at gaitOnly looks at gait No scores No scores
published yetpublished yet
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6-Minute Walk Test6-Minute Walk TestDeveloped to assess exercise tolerance in Developed to assess exercise tolerance in
cardio-pulmonary patientscardio-pulmonary patients Type of Information: Clinician observation and Clinician observation and
ratingrating
Component: Gait distance Gait distance
Equipment needed: Stopwatch, Stopwatch, sphygmomanometer, stethoscopesphygmomanometer, stethoscope
Time to Complete Test: 6-10 minutes 6-10 minutes
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6-Minute Walk Test6-Minute Walk TestSpecifics of testing:Specifics of testing: Encourage patient to Encourage patient to
not talk during testnot talk during test Take vital signs pre Take vital signs pre
and postand post Patient can take Patient can take
standing restsstanding rests Termination of Termination of
testingtesting
04/22/2304/22/23 J Zimney MPT, GCSJ Zimney MPT, GCS 5858
6-Minute Walk Test6-Minute Walk TestScoring:Scoring: Few published Few published
normsnorms < 1000 ft (300m) < 1000 ft (300m)
indicative of indicative of morbidity w/in 6 morbidity w/in 6 months in heart months in heart diseasedisease
Median w/ healthy Median w/ healthy older adults older adults
Mean distance by age:
60-69 years: male 572m, female 538m
70-79 years: male 527m, female 471m
80-89 years: male 417m, female 392m
04/22/2304/22/23 J Zimney MPT, GCSJ Zimney MPT, GCS 5959
6-Minute Walk Test6-Minute Walk TestStrengths:Strengths: Can use assistive Can use assistive
devicedevice Sensitive to change w/ Sensitive to change w/
exercise trainingexercise training Safe due to patients Safe due to patients
self-limiting during self-limiting during testtest
Easy to perform, little Easy to perform, little equipment neededequipment needed
Weaknesses:Weaknesses: Must be able to Must be able to
stand and/or walk stand and/or walk 6 minutes6 minutes
04/22/2304/22/23 J Zimney MPT, GCSJ Zimney MPT, GCS 6060
Kristjansdottir et al 2004Kristjansdottir et al 2004Compared 6-MWT to Limited Graded Compared 6-MWT to Limited Graded
Exercise Test:Exercise Test:6-MWT effectively identified 6-MWT effectively identified cardiopulmonary concerns as did cardiopulmonary concerns as did graded test. graded test.
Conclusion: Good test for Conclusion: Good test for cardiopulmonary cardiopulmonary rehab…….Conditioning????rehab…….Conditioning????
04/22/2304/22/23 J Zimney MPT, GCSJ Zimney MPT, GCS 6161
Timed StandsTimed StandsDesigned to assess strength, mobility and Designed to assess strength, mobility and
enduranceendurance Type of Information: Clinician observationClinician observation
Component: Repeated standing up from Repeated standing up from seated position seated position
Equipment needed: Stopwatch, chair or matStopwatch, chair or mat
Time to Complete Test: 1-2 minutes 1-2 minutes
04/22/2304/22/23 J Zimney MPT, GCSJ Zimney MPT, GCS 6262
Timed StandsTimed StandsSpecifics of testing:Specifics of testing: Can be time to complete 5 reps, reps Can be time to complete 5 reps, reps
completed in 30 or 60 seconds.completed in 30 or 60 seconds. Patient is allowed to use any means Patient is allowed to use any means
necessary for standing up. (record necessary for standing up. (record need for UE’s)need for UE’s)
04/22/2304/22/23 J Zimney MPT, GCSJ Zimney MPT, GCS 6363
Timed StandsTimed StandsScoring: 30 second timed Scoring: 30 second timed
standsstands
Jones CJ, Rikli RE, Beam W. Res Q Exerc Sport. 1999;70:113-119
Normal Normal Range *Range * 60-64 65-69 70-74 75-79 80-84 85-89 90-94
Men 14-19 12-18 12-17 11-17 10-15 8-14 7-12
Women 12-17 11-16 10-15 10-15 9-14 8-13 4-11
*Normal range of scores is defined as the middle 50 percent of each age group. Scores above the range would be considered “above average” for the age group and those below the range would be “below average”.
04/22/2304/22/23 J Zimney MPT, GCSJ Zimney MPT, GCS 6464
Timed StandsTimed StandsScoring: 5 second timed standsScoring: 5 second timed stands
Lord, S.R. et al. J Gerontol A Biol Sci Med Sci. 2002; 57A(8):M539-M543.
Sit to Stand Time (Seconds) by Age and Gender
75-79 80-84 85-89 90+ Total
Men 12.1 (5.4) 12.9 (5.5) 13.7 (7.2) 17.2 (8.0) 12.8 (5.9)
Women 12.2 (4.1) 13.4 (5.6) 14.1 (6.5) 15.1 (6.5) 12.9 (5.1)
(SD) = standard deviation
04/22/2304/22/23 J Zimney MPT, GCSJ Zimney MPT, GCS 6565
Chair Stands as a Measure of Chair Stands as a Measure of LE Strength in Sexagenarian LE Strength in Sexagenarian
WomenWomen 47 women performed 5STS, 30STS, Isokinetic 47 women performed 5STS, 30STS, Isokinetic
testing of hip, knee and ankletesting of hip, knee and ankle Results:Results:
5STS: Ankle PF, Hip Flex & Knee Ext. 5STS: Ankle PF, Hip Flex & Knee Ext. 30STS: Ankle PF 30STS: Ankle PF But both only moderate predictors of LE strength.But both only moderate predictors of LE strength. Other factors: sensorimotor, balance, psychologicalOther factors: sensorimotor, balance, psychological
McCarthy et al. J Geron. 2004;59A(11):1207-1212.McCarthy et al. J Geron. 2004;59A(11):1207-1212.
04/22/2304/22/23 J Zimney MPT, GCSJ Zimney MPT, GCS 6666
Other Functional Other Functional AssessmentsAssessments
Short Physical Performance Battery – Short Physical Performance Battery – tandem stance, 5STS, gait speedtandem stance, 5STS, gait speed
(Guralnik et al. J Geron. 1994;49(2):M85-M94)(Guralnik et al. J Geron. 1994;49(2):M85-M94)
UAB Life-Space Assessment – Assesses UAB Life-Space Assessment – Assesses mobility in 5 designated environmentsmobility in 5 designated environments (Peel et al. Phys Ther. 2005;85:1008-1019)(Peel et al. Phys Ther. 2005;85:1008-1019)
NWRA Obstacle Course – UE dual task w/ NWRA Obstacle Course – UE dual task w/ gait over obstaclesgait over obstacles
04/22/2304/22/23 J Zimney MPT, GCSJ Zimney MPT, GCS 6767
Clinical Decision MakingClinical Decision MakingTests are chosen based on:Tests are chosen based on:1. Facet of gait, balance or mobility 1. Facet of gait, balance or mobility
noted to possibly be deficientnoted to possibly be deficient2. Possible need for referral2. Possible need for referral3. To support care plan, treatment, 3. To support care plan, treatment,
skilled therapy, or establish objective skilled therapy, or establish objective goalsgoals
04/22/2304/22/23 J Zimney MPT, GCSJ Zimney MPT, GCS 6868
More on More on Clinical Decision MakingClinical Decision Making
Individual patient needs guide assessment Individual patient needs guide assessment choice but setting distinctions may include:choice but setting distinctions may include:
Acute care, ALF, SNF, LTC & HH: Acute care, ALF, SNF, LTC & HH: TUG, 6MWT, Timed Stands, PPTTUG, 6MWT, Timed Stands, PPT
Outpatient: BBS, ABC, mFES, PPT, DGI, TUG, Outpatient: BBS, ABC, mFES, PPT, DGI, TUG, Timed Stands, 6MWTTimed Stands, 6MWT
Community Outreach/Screening: TUG, Timed Community Outreach/Screening: TUG, Timed Stands, ABC, mFESStands, ABC, mFES
NOTE: These are only generalities, do NOT limit the choice of NOTE: These are only generalities, do NOT limit the choice of test based on setting.test based on setting.
04/22/2304/22/23 J Zimney MPT, GCSJ Zimney MPT, GCS 6969
What do we do What do we do now?now?
What treatments work?
04/22/2304/22/23 J Zimney MPT, GCSJ Zimney MPT, GCS 7070
What therapeutic interventions What therapeutic interventions work?work?
Strength and ConditioningStrength and Conditioning FlexibilityFlexibility Speed/power trainingSpeed/power training Dual-task/attention trainingDual-task/attention training Functional trainingFunctional training Cognitive TrainingCognitive Training
04/22/2304/22/23 J Zimney MPT, GCSJ Zimney MPT, GCS 7171
Land vs. Aquatic ExerciseLand vs. Aquatic Exercise 11 older adults (ALF and outpatient) 11 older adults (ALF and outpatient)
Berg Balance Scale <47/56Berg Balance Scale <47/56 Comparable exercises on land and in Comparable exercises on land and in
water. 2x/wk x 6 weeks.water. 2x/wk x 6 weeks. Results: Significant improvements but Results: Significant improvements but
no difference between H2O and land-no difference between H2O and land-based.based.
Douris et al. J Ger PT. 2003;26(1):3-6.Douris et al. J Ger PT. 2003;26(1):3-6.
04/22/2304/22/23 J Zimney MPT, GCSJ Zimney MPT, GCS 7272
Eccentric WorkEccentric WorkLaStayo et al. compared LaStayo et al. compared
cardipulmonary rehab with LE cardipulmonary rehab with LE eccentric resistance in frail elderly. eccentric resistance in frail elderly.
Results: Eccentric work group showed:Results: Eccentric work group showed:↓ ↓ in TUG (16.65 to 11.96 seconds)in TUG (16.65 to 11.96 seconds)↑ ↑ in Berg (49.7 to 53.4)in Berg (49.7 to 53.4)
LaStoya et al. J Geron. 2003;58A(5):M419-424.LaStoya et al. J Geron. 2003;58A(5):M419-424.
04/22/2304/22/23 J Zimney MPT, GCSJ Zimney MPT, GCS 7373
Innovative treatment ideas:Innovative treatment ideas: Dynadiscs (static vs. dynamic balance)Dynadiscs (static vs. dynamic balance) ? One-legged stance? One-legged stance Corner vs. CountertopCorner vs. Countertop Eyes closed or not?Eyes closed or not? Lite GaitLite Gait Dual taskingDual tasking Backward gaitBackward gait Speed trainingSpeed training Conditioning and strengtheningConditioning and strengthening
04/22/2304/22/23 J Zimney MPT, GCSJ Zimney MPT, GCS 7474
Fall Prevention and You!Fall Prevention and You! Falls Free: Promoting A National Falls Falls Free: Promoting A National Falls
Prevention PlanPrevention Plan V15.88 History of Fall, new diagnosis V15.88 History of Fall, new diagnosis
codes to be implemented on October codes to be implemented on October 1, 2005 1, 2005
Falls Free ProgramFalls Free Program
04/22/2304/22/23 J Zimney MPT, GCSJ Zimney MPT, GCS 7575
04/22/2304/22/23 J Zimney MPT, GCSJ Zimney MPT, GCS 7676
Case Study #1: EarlCase Study #1: Earl 78 yo male 5 days post prostate 78 yo male 5 days post prostate
surgery onset of LE weaknesssurgery onset of LE weakness PMH CABG, “CVA’s”, SeizuresPMH CABG, “CVA’s”, Seizures PLOF: Highly active, Lived I, Walked PLOF: Highly active, Lived I, Walked
dog in park daily, Phase III cardiac dog in park daily, Phase III cardiac rehab.rehab.
04/22/2304/22/23 J Zimney MPT, GCSJ Zimney MPT, GCS 7777
Case Study #2: JuliaCase Study #2: Julia 82 yo female fell 6/04 w/ L hip fx w/ 82 yo female fell 6/04 w/ L hip fx w/
THATHA No falls since but is “very afraid”No falls since but is “very afraid” Meds: Plendil, Diovan, LexiproMeds: Plendil, Diovan, Lexipro PMHx: CVA 11 years ago, HTNPMHx: CVA 11 years ago, HTN
04/22/2304/22/23 J Zimney MPT, GCSJ Zimney MPT, GCS 7878
Case Study #3: BillCase Study #3: Bill 75 yo male w/ hx 4-5 falls in last 6 75 yo male w/ hx 4-5 falls in last 6
mos. Latest fall, “reached to floor mos. Latest fall, “reached to floor and just rolled”.and just rolled”.
PMHx: MVA w/ TBI & R LE fx ’60, R PMHx: MVA w/ TBI & R LE fx ’60, R RTC repair, C5-6 discectomy, CABG x RTC repair, C5-6 discectomy, CABG x 4, NIDDM4, NIDDM
Wife and dau assist prnWife and dau assist prn
04/22/2304/22/23 J Zimney MPT, GCSJ Zimney MPT, GCS 7979
Case Study #4: ShirleyCase Study #4: Shirley 64 yo female w/ severe onset of 64 yo female w/ severe onset of
dizziness that lasted 3-4 days, no just dizziness that lasted 3-4 days, no just “very unsteady”.“very unsteady”.
PMHx: dizziness onset 5 yrs ago, PMHx: dizziness onset 5 yrs ago, Hypothyroidism, Breast CAHypothyroidism, Breast CA
Meds: SynthroidMeds: Synthroid No Health InsuranceNo Health Insurance
04/22/2304/22/23 J Zimney MPT, GCSJ Zimney MPT, GCS 8080
Case Study #5: Myrt Case Study #5: Myrt 84 yo female 7/4/04 reaching to close 84 yo female 7/4/04 reaching to close
trunk when struck by car, fell w/ pelvic trunk when struck by car, fell w/ pelvic fx.fx.
3 weeks in nursing home3 weeks in nursing home Sister reports multiple fallsSister reports multiple falls c/o back pain, using quad cane, FWWc/o back pain, using quad cane, FWW PMHx: nothing significantPMHx: nothing significant Meds: Zetia, Multivitamin, NaproxynMeds: Zetia, Multivitamin, Naproxyn