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Evidence-Based Balance Rehabilitation and Fall Prevention: Summary
Muscle strength : • Adequate knee strength to prevent buckling and ankle strength to counter sway: ○ Hip weakness can reduce COM control • Spinal and shoulder girdle weakness can alter posture and effect dynamic balance Range of motion (ROM) : • Ankle contracture/triceps surae tightness results in posterior ground reaction force • Leading to forward posture, which leads to hip/trunk contractures to counteract this force FALLS Risk Factors for Falls • History of falls: How many/frequency, last time, any injuries, location, activity • Gait issues: Slow gait speed (<1.0 m/s); difficulty on stairs, turns; assistive device (AD) • Polypharmacy (>3 to 4 meds): Especially antihypertension (HTN), but also sedatives • Psychological issues: Depression, fear of falling (FoF), sedentary lifestyle, cognitive decline • Difficulty with activities of daily living (ADL) • Advanced age • Visual impairments Effects of Aging • Balance is diminished in older versus younger adults • Gait impairments: Decreased step/stride length, and hip extension • Difficulty with unexpected perturbations • Sarcopenia: Especially weakness in hip extensors, knee extensors, ankle dorsiflexion/plantarflexion (DF/ PF) • Vestibular function decline: Hair cell loss and neuronal degeneration • Visual decline: Acuity, field of vision, judging distances/spatial relationships • Cognitive decline: Attention (especially with dual tasking) Fear of Falling (FoF) Directly related to lower functional ability and perceived self-efficacy: • A history of falling or even impaired mobility can lead to FoF Strategies to Reduce Fall Risk • Take a systematic and pragmatic approach to therapy: ○ Assess looking for specific impairments based on systems ○ Prioritize and time interventions appropriately
• Work as a team: Refer appropriately to SLP, OT, PT, physician, nurse, pharmacist, psychologist/counselor, social worker/case manager, family • Get involved in the community: ○ Screening and education opportunities ○ Exercise and activity groups THERAPY ASSESSMENT AND INTERVENTION Step 1 : Determine what deficits and limitations are most affecting balance: • Comprehensive evaluation • Careful observation Step 2 : Prioritize impairments to address the following: • Strength and flexibility first • Vertical orientation of balance • Balance strategies, sensory reweighting, reaction timing, and so on Comprehensive Assessment History and subjective : Medical history, fall history, AD use, medication review, questionaires. ROM and flexibility : Ankle DF, hip extension, spinal motion, knee flexion/extension, UE ROM. Muscle strength : Knee extension, hip flexion/ extension/abduction, ankle muscles. Sensory Testing • Somatosensation • Visual • Vestibular Sensory Integration Testing • Romberg : Standing feet together eyes open and eyes closed for 30 sec • Sharpened Romberg : Tandem standing eyes open and eyes closed for 30 sec • Modified Clinical Test of Sensory Integration in Balance (CTSIB-M) : Vision, vestibular and somatosensory Balance Tests • Standing balance assessments : ○ Berg Balance Scale: considered gold standard test, but not much in terms of dynamic balance • Sit to stand assessments : ○ 5× sit to stand • Walking balance assessments : ○ Dynamic Gait Index (DGI) Hybrid Tests • MiniBEST : An amalgamation of several balance tests (Berg, DGI, CTSIB-M, TUG) as well as balance perturbations and testing for retropulsive balance
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