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Evidence-Based Balance Rehabilitation and Fall Prevention: Summary
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 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)
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