○ Independent static standing balance with feet together; increased sway with eyes closed. ● Locomotion: ○ Independent gait indoors using furniture for assist or cane. ○ Slow gait speed (2.3 ft/s), which declines even further during dual tasking, and while walking on uneven surfaces. ○ Very slow negotiation of steps; needs a rail; avoids steps when possible. ● Cognition: Mild cognitive decline typical for her age. ● Communication: Alert and oriented, occasionally despondent when homebound. ● Psychosocial: Anxious about falls, loss of independence Motor control ROM/Posture: moderate kyphosis, neutral hip/knee extension and ankle dorsiflexion, limited cervical ROM secondary to peripheral vestibular hypofunction and BPPV confirmed by semicircular canal testing Sensation: minimal peripheral neuropathy in bilateral feet, loss of protective sensation on soles of both feet with monofilament score of 5/10; vision corrected with bifocals. Muscle Strength: Functional Manual Muscle Testing and Observation Joint/Area Bilateral Comments Neck flexion/extension 4 Head control: Good. Upper trunk/Scapular 4 Trunk control: Good.
● 30-Second Chair Stand at five attempts. ● Dynamic Gait Index (DGI) 5/24 due to assistance needed with most tasks on exam. ● mCTSIB results were 30 seconds, 30 seconds, 15 seconds, and 5 seconds in positions 1 to 4. Questions 1. Which risk factor for falls is the best predictor for future falls? 2. Which fall risk outcome measure would be the most appropriate for Irene? 3. Which sensory system does Irene rely on for balance? 4. Which fall prevention exercise program would be the most effective approach for Irene? 5. Which combination of fall risk factors should be addressed initially in order to have the most effect on future fall risk? Responses 1. Irene has several risk factors for falls. Her recent injurious fall is the best predictor of future falls, but she has additional risk factors, including being female, her advanced age, her slow gait speed, her poor balance as evidenced by sitting at the bedside to dress, decreased lower extremity strength as evidenced by manual muscle testing and chair-stand test, history of vestibular hypofunction that could cause dizziness, polypharmacy, and cognitive decline. Irene also scored as being at risk for falls on every one of her outcome measures (all STEADI tests, ABC, mCTSIB, and DGI). 2. The TUG fall risk screening measure would be a good choice for Irene as it best matches her physical abilities out of the outcome measures listed. The Functional Reach exam would require assistance for Irene as she needed help while reaching in standing, and thus be too difficult. The Functional Gait Assessment would also be too difficult for Irene as it incorporates several high level balance activities. The DGI might be a consideration, but when it was performed, Irene’s score was only 5/24, indicating that it was also too challenging. Irene was able to perform the TUG requirements without physical assistance. 3. Irene relied on her visual system for balance as evidenced by her mCTSIB performance. Irene’s history of lower extremity sensory loss and vestibular hypofunction could also affect her reliance on vision. 4. Irene would benefit from the Otago exercise program, which has been proven to decrease falls in homebound older adults. Irene meets the definition of a homebound older adult. She would benefit from strengthening, balance training, and walking, all of which are included in the Otago program, which is supervised and progressed by a clinician. 5. Research indicates that early fall prevention interventions should include lower extremity strengthening, balance exercise, and correction of home hazards in order to have the most immediate effect on fall prevention. Research does not indicate at this time that reducing fear of falling or improving somatosensation alone will have an immediate effect on future falls. ● Adults with a single fall or with difficulty with gait or balance screenings should have a multifactorial fall risk evaluation performed by a trained clinician. ● Older adults with a single fall but no trouble with gait or balance do not need a multifactorial fall risk assessment. A multifactorial fall risk assessment should include the following: ● History of falls. ● Medication review of relevant medical risk factors. ● Detailed evaluation of gait, balance, and mobility. ● Detailed neurologic evaluation. ● Assessment of lower extremity strength, cardiovascular status, visual acuity, and feet and footwear. ● Assessment of ADLs, fear of falling, and their home environment.
Lower trunk/ Abdominals
3+ Irene is 20 lbs overweight.
Shoulder
4-
Elbow
4
Wrist
4- 4-
Hand/Fingers
Hip
3+
Knee
3+ Complains of mild knee pain during testing.
Ankle
4-
Mild edema noted.
Foot/Toes
4-
Mild edema noted.
Outcome measures ● ABC score 55/100. ● TUG score 15 seconds. ● TUG cognitive 20 seconds. ● Four-Stage Balance Test: could not maintain tandem stance more than 5 seconds. Conclusion This course has exposed the learner to compelling information that described the falls epidemic, a healthcare emergency for older adults. Anyone over 65 years of age is at risk for falls simply because of their age. This risk is compounded by the numerous intrinsic and extrinsic factors that influence an older adults’ ability to respond physically, mentally, and socially to falls and to their consequences. Through accurate screening for fall risk, differential diagnosis of the fall etiology, and effective multifactorial treatment planning, knowledgeable therapists can have a positive effect on the quality of life of older adults at risk for falls. Several national health organizations have reviewed or conducted research and their recommendations can be summarized as: ● Ask all older adults about falls and injurious falls in the past 12 months. ● Ask all older adults if they have difficulty with balance or walking.
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Book Code: PTCA2622B
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