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.
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 buckling stress. Areas tested on each foot include the metatarsal heads of the first, third, and fifth toes, the end of the first toe and the end of the third toe, staying away from wounds or callouses. This type of sensory testing is a screen for determining if the older adult has at least protective sensation on the soles of the feet and can trigger a more in depth sensory examination if 6 or less of the 10 areas tested display normal sensation (Migliarese, 2017). Figure 4 shows the areas to test on the soles of the feet. Vestibular deficits may manifest themselves in performance on the mCTSIB, difficulty with head turns during gait, or by complaints of dizziness. Peripheral vestibular hypofunction is a common problem in older adults, making it important to assess this system in more detail for those who complain of dizziness, unsteadiness, or lightheadedness. Older adults may not use these terms to describe “dizziness” or even realize that these types of sensations are not a part of normal aging. Adults who perform poorly on the mCTSIB, have unsteady gait with head turns, or who have complaints that indicate dizzy sensations with head movements should undergo a thorough vestibular evaluation by a clinician with expertise in this area. Figure 4. Monofilament Testing
Dual-tasking Additional neurologic assessments should investigate the ability to dual-task during gait, especially if the clinician suspects cognitive decline that may affect mobility. Older adults show deficits in motor tasks when challenged to perform more than one activity at a time. Research has demonstrated that deterioration in gait during dual-task testing compared with single-task performance is associated with increased fall risk (Muir-Hunter & Wittwer, 2016). However, at this time, evidence is lacking that could recommend which dual-task testing procedures should be used in clinical practice. Commonly used dual-task exams are the TUG Cognitive Test (TUG cog) and the TUG Manual Test (TUG man). For the TUG cog test, individuals are given verbal instructions to stand up from a chair, walk 3 m as quickly and safely as possible, cross a line marked on the floor, turn around, walk back, and sit down. This is timed as the person counts backward by threes from a randomly selected number between 20 and 100 (Maranhao-Filho, Maranhao, Lima, & Silva, 2011). For the TUG man, individuals must follow the same instructions for walking as in the TOG cog, but instead of counting backward they hold a cup filled with water (Hofheinz & Schusterschitz, 2010). If a walker is required for safe gait, then the manual task may be difficult to execute. Vital signs and cardiovascular exam A thorough fall risk evaluation also should include examination of the cardiovascular system. The cardiovascular exam should include checking heart rate and rhythm, postural pulse, and orthostatic hypotension which is a risk factor for falls. Adults who describe feeling lightheaded with changes in positions should be evaluated for orthostatic hypotension. The STEADI site includes a printable assessment handout for orthostatic hypotension (https://www.cdc.gov/steadi/pdf/STEADI-Assessment- MeasuringBP-508.pdf), which includes the following instructions: 1. Have the patient lie down for 5 minutes. 2. Measure blood pressure and pulse rate in supine. 3. Have the patient stand. 4. Repeat blood pressure and pulse rate measurements after standing 1 and 3 minutes. A drop in blood pressure of 20 mm Hg or more, or in diastolic blood pressure of 10 mm Hg or more, or experiencing lightheadedness or dizziness is considered abnormal (CDC/ STEADI, 2017). Therapists should also note use of medications for cardiovascular conditions, such as hypertension, arrhythmias, or other types of pharmacologic agents that could influence blood pressure or heart rate response to exercise.
Note . From Western Schools, 2019.
EliteLearning.com/Physical-Therapy
Page 70
Powered by FlippingBook