Posture A general posture evaluation should be performed as part of the occupational or physical therapy evaluation, paying special attention to FHP and presence of kyphosis. An older adult who displays kyphosis and/or FHP may maintain static and dynamic stance toward the anterior limits of stability, creating an increased risk for falling forward even when perturbed by small forces from behind. A Reedco postural screening form is a commonly used assessment tool for posture (Booshanam, Cherian, Joseph, Mathew, & Thomas, 2011). Recent studies have linked FHP with increased risk for falls, possibly due to abnormal cervical proprioceptive feedback or abnormal vestibular feedback that must be integrated into effective balance and postural control strategies (Kang et al., 2012). Screening for geriatric posture can be accomplished using a Reedco Posture Scale (RPS), which includes visual observation of 10 postural traits that are assigned a value on a 0 to 10 ordinal scale (Gunther et al., 2005).However, this method has not proven to be as reliable for best practice. Cervical ROM can be reliably measured with instruments such as the Cervical Range-of-Motion device (Tousignant et al., 2006) and FHP can be measured in older adults by determining the craniovertebral angle via photographic imaging (Nemmers, 2009). The craniovertebral angle is an angle formed by a horizontal line drawn through the spinous process of the seventh cervical vertebra (C7) and a line joining the spinous process of C7 vertebra with the tragus of the ear (Yip et al., 2008; see Figure 2). The Kyphosis Index (Lundon, Li, & Biberstein, 1998) is an additional method of postural evaluation that involves placing a flexicurve ruler along the spine and then tracing the spinal curve on a grid paper. Figure 2: Forward Head Posture Measurement
Functional mobility and ADLs Functional mobility and ADL performance is a standard component of any occupational or physical therapy evaluation and should definitely be included in a detailed fall risk assessment. Older adults with high fall risk may be avoiding certain movements or activities because of a previous fall, fear of falling, or poor self-efficacy with certain activities. For example, an adult at risk for falls may dress sitting down at the edge of a chair versus standing on one leg to pull on pants or put on sock and shoes. They may avoid standing in a wet shower to bathe and instead bathe at the sink while standing or seated. They may no longer engage in community outings that require more challenging mobility skills such as negotiating stairs without a rail, walking in dark environments or on uneven surfaces. Surveys such as the Activities-Specific Balance Confidence Scale (ABC; Nemmers & Miller, 2008) or the Modified Falls Efficacy Scale (Tinetti, Richman, & Powell, 1990), which will be discussed later in the course, can help identify avoidance behaviors and changes in ADL performance. Neurologic examination A general neurologic evaluation contains many components familiar to clinicians that will not be covered in detail here. This section will emphasize the basic neurologic components more likely to affect fall risk, although clinicians should keep in mind that areas such as reflexes, coordination, and cranial nerve testing may in indicated in older adults with chronic neurologic conditions or signs and symptoms of potential neurologic pathology. Sensory integration When performing a full neurologic examination there are important areas to emphasize that can contribute to fall risk in older adults. Recalling the earlier discussion of sensory integration and balance, inputs from three sensory systems should be examined for normal functioning, including vision, somatosensation, and vestibular afferent information. The modified Clinical Test of Sensory Interaction on Balance (mCTSIB; Figure 3) can identify use of these three systems to maintain static standing balance in each of four to six positions, depending on which version of the assessment is used. The four-position mCTSIB includes static stance with feet together in a firm surface with eyes open, then with eyes closed, followed by stance on a 3-inch dense foam with feet together with eyes open and then with eyes closed. The target is 30 seconds in each position. See Figure 3 for testing positions.
Note . From Western Schools, 2019.
Figure 3: Modified Clinical Test of Sensory Interaction and Balance
A: Eyes open on firm surface
B: Eyes closed on firm surface
C: Eyes open on foam surface
D: Eyes closed on foam surface
Note . From Western Schools, 2019.
Sensory testing Sensory testing should include vision, somatosenation, and vestibular function. Visual acuity should be tested using a Snellen eye chart (Schwiegerling, 2004). Older adults should be asked if their vision has been checked on at least an annual basis.
Somatosensation is particularly important to test on the soles of the feet, which can be accomplished using Semmes-Weinstein monofilaments to test five spots on the bottom of each foot, for a total of 10 areas assessed (Migliarese, 2017). Monofilaments are made of single fiber nylon thread that generate reproducible
Page 135
Book Code: PTCA2622B
EliteLearning.com/ Physical-Therapy
Powered by FlippingBook