Fall Risk Reduction Program Designing an Exercise Program

Module #3

Shelley Thomas, MPT, MBADara Coburn, M.S., CCC-

SLP

Fall Risk Reduction Program: Review of Modules 1 & 2

In the first module we reviewed the premise of the Fall Risk Reduction Program, including the inclusion criteria for patient selection

The second module reviewed patient assessment Identifying patients at risk of falling Evaluating patients in a dual task condition to

simulate “real life” situations

Fall Risk Reduction Program: Module 3

In this module, we will delve furtherinto patient assessment. You have identified patients at risk for falling and evaluated performance under dual task conditions. Now you must further do further assessment to identify the system(s) of balance most responsible for the falls, and develop an plan of care to address the system(s).

Agenda Screening & Assessing Balance Impairments: Information to

gather in order to design an exercise program Exercise selection Designing a program

Agenda Screening & Assessing Balance

Impairments: Information to gather in order to design an exercise program

Exercise selection Designing a program

Multifactorial Risk Assessment

Focused HistoryPhysical ExaminationFunctional AssessmentEnvironmental Assessment

American Geriatric Society Clinical Practice Guidelines: Prevention of Falls in Older Adults

Multifactorial Risk Assessment: Focused History

History of falls – need detailed description of the fall circumstances, frequency, symptoms

Medication review

History of risk factors – acute & chronic medical issues

Multifactorial Risk Assessment – Physical Exam

Physical function - Gait, balance (including postural reflexes), mobility, and lower extremity joint function

Neurological function – Cognitive evaluation, peripheral nerve function, proprioception, reflexes, and tests of cortical, cerebellar, & extrapyramidal function

Muscle strength Cardiovascular status – Heart rate, postural pulse, blood

pressure Visual acuity Vestibular function (oculomotor tests, positional testing) Examine feet and footwear

Multifactorial Risk Assessment – Functional Assessment

Assess activity of daily living (ADL) skills

Perceived functional ability and fear of falling

Multifactorial Risk Assessment – Environmental Assessment

Home safety

Other environment factors as needed

Turning the multifactorial risk assessment into an exercise program – What

to do with all this information?

Stratify the Patient Problems into Systems of Balance

Musculoskeletal System Proprioceptive System Oculomotor System Vestibular System Cognition/Communication

Musculoskeletal System Muscle, tendons, ligaments, bones, joints, and

associated tissues that move the body and maintain form

Key muscle groups associated with walking and upright balance reactions: Hip flexors Hip extensors (especially gluteous maximus) Hip Abductors (especially gluteous medius) Knee extensors (quadricepts Knee flexors (hamstrings) Plantarflexors (gastrocnemius, soleus) Dorsiflexors Upper and lower abdominal muscles

Proprioceptive System

Proprioception is the unconscious awareness of body position. It tells us about the position of our body

parts in relationship to each other and the environment.

It allows us to have a knowledge of how much force and speed the muscle is required to generate in order to accomplish a specific movement which results in appropriately graded muscle control.

Oculomotor System

Is the control system that coordinates the 12 muscles which accurately direct our eye movements.

Three main types of Oculomotor Skills: Saccades – The ability to quickly and

accurately make eye movements or jumps from one target to another.

Fixation – The ability to maintain steady visual attention on a target.

Pursuits – The ability to smoothly follow a moving target.

Vestibular SystemSystem of the body

that is responsible forspatial orientation andbalance.

The vestibular system sends information to the brain about the location of one's head in space.

Vestibular, Oculomotor, Proprioception Systems: Need at least two

In order to maintain balance, at least two of these systems must be sending balance information to the brain at any time.

Examples: If in the dark, brain can use proprioceptive

and vestibular inforamation to remain upright against gravity.

If have lower extremity amputation, can use vestibular and oculomotor systems.

If have labrynthiasis impacting vestibular system, can use oculomotor and proprioceptive information.

Cognition & Communication Systems (involved in dual tasking)

Cognition is the ability to think and process information Attention, memory, processing, problem solving, judgment,

impulse control, and executive skills.

Communication is the ability to exchange and comprehend language. Naming, word finding, following directions, answering

questions, speaking, and writing.

How much of the “cognitive pie” does mobility take? If maintain balance “hogs” resources, decreases cognitive and communication skills. Places person in an either/or situation – can maintain balance

or focus on cognitive task.

Sample Patient Problem ListMusculoskele

talProprioceptio

n Oculomotor Vestibular Cognition

Peripheral Neuropathy X

Lower extremity strength rated 3/5 X

Flexed posture X X X

Inadequate footwear X

Decreased visual acuity due to diabetic retinopathy

X

Decreased problem solving skills

X

Impaired balance reactions X X X

Now that you have stratified the problems into the systems of

balance, you can design a plan of care that incorporates

Interactive Metronome

Why include Interactive Metronome in the plan of care?

Movement Requires Directed attention Pathologies that disrupt motor timing and

sequencing lead to inaccurate movements IM & Dual Tasking

IM requires a patient to focus on auditory stimuli and make a motor response to hit the trigger on the beat.

Must decide if need to slow down, speed up, or remain consistent.

Computer can measure performance in milliseconds, so act at same speed as muscular contractions.

Helps patients identify their own timing tendency and learn how to counteract own tendencies.

Fall Risk Reduction Program Exercises

This library of exercises are suggestions. Concept is to design exercises, using the Interactive Metronome that target specific problem areas

Center treatment interventions around long and short term goals that are important to the patient. Goal selection was discussed in the second module

Download can be found on course materials page

Musculoskeletal System Exercises*Photos and exercise descriptions available on course materials page

Leg Squats Alternate SteppingLunges Stepper with WeightsHeel Raises BridgingLong Arc Quads Abdominal CrunchTaps Ups Postural Alignment

Lateral Tap UpsPostural Alignment with Marching

Proprioceptive System Exercises*Photos and exercise descriptions available on course materials page

Clock Clapping with Eyes Closed, Seated

Uneven Surface with Eyes Open

Clapping with Eyes Closed, Standing

Uneven Surface with Eyes Closed

Oculomotor System Exercises*Photos and exercise descriptions available on course

materials page

UNO Poster Board Visual SequencingVisual Memory Recall/recognition

Vestibular System Exercises*Photos and exercise descriptions available on course

materials page

Head Movement in Supine Sidelying to Sit with Head RotationHead Movement in Sitting Visual tracking focal itemHead Turns with Reaching Across Midline In Sitting, Head stationary, Saccades

Head Turns with Walking Using the in-Motion Triggers

Rolling Seated, Reaching Across and Behind to hit target

Cognition/Communication System Exercises

*Photos and exercise descriptions available on course materials page

STROOP Activities Yes/No Questions Selected and Divided Attention

Aphabetizing Naming Visual AttentionSorting Word Finding MemorySequencing Melodic Intonation Picture IdentificationImpulse Control Intelligibility Drills Following DirectionsSafety Awareness Oral Motor Exercises Setting Table

Fall Risk Reduction Poster Overview

Fall Risk Reduction Best Practices Kit

Contains: 1 – STOOP Board (12” x 18”) 5 – Fill-in-the-Blank Cards (4” x 11”) 5 – Melodic Intonation Cards (4” x 11”) 15 –Object Cards (7½” x 6”) 1 set – 1 – 12 Numbered Cards (8½” x 4”) 1 set – Yes/No Cards (4” x 8½”) 1 set – 1 – 25 Numbered Cards (4” x 3”) 15 – Word Cards (2½” x 3) 1 set – Various Sized Squares

1 – 12 Numbered

Cards

Object Cards

STOOP Board

Word Cards

Various Sized

Squares

1 – 25 Numbered

Cards

Yes/No Cards

Fill-in-the-Blank Cards

Melodic Intonation

Cards

Integrating Kit Items for Fall Risk Reduction Tasks

Toe Tapping Clock

Visual MemoryMemoryNaming

Picture Identification

STROOP Activities

Alphabetizing

Sorting

Sequencing

Yes/No Questions

Word FindingMelodic

Intonation

"Homework"

Complete following worksheet to develop a plan of care for your patient. Use the same patient as in Module #2.

Post-test

Complete post-test to receive link for Module # 4 of 6

Materials Page This video PowerPoint Module 3 Homework Exercise Guide Poster Best Practices Kit www.interactivemetronome.com/index

.php/fall-risk-coaching

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