19
Evidence-Based Balance Rehabilitation and Fall Prevention: Summary
Special Tests • Lateropulsion : Burke Lateropulsion Scale • Retropulsion : Mini BEST • For ataxia : Coordination testing Cognition • Montreal Cognitive Assessment (MoCA) • Selective attention/task switching tests: Trails Making Test Standardized Tests • One component of a comprehensive balance assessment • Focus on key deficits of balance such as difficulty with narrow BOS items, head turns, posterior LOB • Note direction of loss, presence/absence of balance strategies THERAPY INTERVENTION Strength Training • Hip muscles (flexors, extensors, abductors) • Ankle muscles (dorsiflexors and plantarflexors) • Progressive strength program: ○ Overload principle: Work at 30% to 80% 1 repetition max (RM) (or 3 × 8 to 10 reps at moderate difficulty) ○ Eccentric exercise: Easier on joints with higher loads, more rapid strength gains Flexibility Training • Ground reaction forces at foot/ankle, hip extension, spinal flexibility • Interventions that target axial rigidity in PD reduce fall risk and improve gait and balance Vertical Reorientation 1. Self-awareness : For all types of dysfunction, use vestibular/somatosensory systems to highlight issues (controlled falling) 2. Sensory exploration : ○ Visual feedback strategy: Bring attention to vertical objects in environment and patit’s relationship to them ○ Use of solid surfaces/support to facilitate acceptance of position and reduce pushing resistance 3. Active learning : Take stable positions and then exploring available space/limits of stability actively, not passively: ○ For lateropulsion: Gait training against wall or mat table ○ For retropulsion: Gait training while pushing against resistance—use weighted shopping cart, walker (D rollator like the U-Step), or gait trainer
4. Functional transfer : Work away from support surfaces into functional activities: ○ Bed mobility, transfers, walking challenges and differing environments, progressively more complex tasks Balance Reactions • Slips and trips are the leading cause of falls during walking in the elderly • Most therapy balance interventions are designed for balance maintenance, not balance recovery Perturbation balance training (PBT): Sudden external perturbations that cause unexpected losses of balance that would otherwise cause a fall: • PBT effective to improve balance recovery and decrease falls • Task specificity of PBT: Forces step reactions training automatic responses Sensory Reweighting Reweight sensory reliance by limiting and/or accentuating a given modality: • Visual (lighting challenges), proprioception (surface challenges), vestibular (vibration challenges) • Rhythmic auditory stimulation paired with balance training Feedforward Balance Use activities that require planning and strategy: • Obstacle courses, object hunts, dual task activities • Simulate real-world activities: Cluttered environments, environmental distractions (people, noise, light contrast, etc.) Dual Task Training Most daily functional tasks require dual tasking: • Decreased dual task ability is associated with more falls and worse balance Compensatory Strategies • Challenge during rehabilitation to tenable levels: Heel posts, bracing and/or assistive device, external support (therapist or harness) • Safety for long-term deficits that are not “rehabable”: AFO, cruising, assistive devices New Technology • Virtual reality (VR) balance training: ○ XBOX Kinect, Nintendo Wii Fit, BITS to fully immersive with VR goggles • Whole body vibration (WBV): Vibration applied via vibrating platform (e.g., AIBI Power Shaper)
Powered by FlippingBook