3/4/2019

CURRENT CONCEPTS IN INTRODUCTION

BALANCE AND FALL • When I say “Fall” what do you think of? PREVENTION

GEOFF MOSLEY, PT, NCS

INTRODUCTION INTRODUCTION

• When I say “Fall” what do you think of? • When I say “Fall” what do you think of?

INTRODUCTION INTRODUCTION

• When I say “Fall” what do you think of? • When I say “Fall” what do you think of? • Therapists are preconditioned to think of falls • But are we addressing fall prevention with every patient? • What are the factors we should be paying attention to? • What works? What doesn’t?

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INTRODUCTION WHAT IS ?

• Issues with balance assessment and treatment: Intact sensory • It is a confusing topic: system • Ever expanding list of risk factors Demands of Central • Assessment tools that only look at small piece of the puzzle the task processing • Interventions that are either poorly defined or poorly researched • Purpose of this course: • To describe the various aspects of balance and how they interact Balance Intact motor Mental health • To introduce a paradigm for how to best assess these factors AND system • To outline treatment strategies that address as many of these factors as possible—there can be a lot, so you might need help! (teamwork!) Cardiovascular Environment health

WHAT IS BALANCE? WHAT IS BALANCE?

Intact sensory Intact sensory system system Demands of Central Demands of Central the task processing the task processing

Intact motor Circumstances system Intact motor Circumstances Balance system Balance

Motivations Environment and Goals Mental health Environment

Cardiovascular Cardiovascular Mental health health health

WHAT IS BALANCE? WHAT IS BALANCE?

Intact sensory Intact sensory system system Demands of Central Demands of the Central the task processing task processing

Intact motor Circumstances system Intact motor Circumstances system

Motivations Environment and Goals Motivations and Balance Balance Environment Goals

Setting (Institutional, Cardiovascular community, health Involvement of Cardiovascular etc.) Others health Involvement of Mental health Motivations and Others Mental health Motivations Goals and Goals

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WHAT IS BALANCE? WHAT IS BALANCE?

Miriam-Webster definition (2017) stability produced by even distribution of weight on each side ? of the vertical axis physical equilibrium the ability to retain one's balance ? Balance ? • Online-medical-dictionary.org (2017) • A Posture in which an Ideal Body Mass distribution is achieved. Postural balance provides the body carriage stability and conditions for normal functions in ? stationary position or in Movement, such as sitting, standing, or Walking. • How do our definitions influence our practice?

BALANCE FROM THE INSIDE: PERCEPTION OF BALANCE THE GRAND HIERARCHY OF BALANCE • Sense of verticality doesn’t just • 1. Sensory: , visual, and vestibular come from the traditional “3”—

• 2. Automatic responses (reflexes) at spinal level • Somatosensory is more than just foot proprioception (a full stomach affects balance!) ): • 3. Higher level responses from cerebellum, basal ganglia, and brain stem (still automatic) (Trousselard, et al, 2004)

• 4. Cortical control (slower reaction than other areas→mostly for feedforward and critical events) • Underwater study (Jarchow & Mast,1999) • 5. Neuromuscular reaction must be fast and strong enough to correct balance • Integration of vestibular and body somatosensory (especially from trunk proprioceptors) in the thalamus (Anastasopoulos & Bronstein,1999)

PERCEPTION OF BALANCE PERCEPTION OF BALANCE

• Role of vision: • Closed loop vs Open loop control • Peripheral vision is more sensitive for movement (“car rolling” phenomenon) • • Closest 10’ is most important for balance (why pts look at their feet?) Closed loop=using sensory feedback to regulate balance • Open loop=using preplanned balance strategies (for instance, increased joint stiffness) to • Subjective Vertical control balance • Aubert effect— • Elders tend to use a more open loop strategy for balance (Tuunainen et al, 2014) • Vertical is biased to body position (the more you lean to one side, the more the SV tilts) (Mast & Jarchow, 1996 and 1999) • Not just affected by body position but difficulty judging visual vertical (Ceyte, et al, 2009) • Somatosensory deficit (hemianesthesia) abolishes effect (Barra, et al, 2010 and Anastasopoulos & Bronstein,1999) • Effect of altered SVV and SBV on balance • Lateropulsion, Contraversive pushing…retropulsion?

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CONTROL OF BALANCE ALL HAIL KING CORTEX

• “Automatic” responses • What exactly does the cortex do in balance? • Fast→spinal reflexes (≈20 msec) (Muscle spindle and GTO mediated) • Role of planner and feedforward • Brain stem, cerebellum, basal ganglia (>200 msec) • Adjustments in plan→adapt to situation • Pre-learned motor plans (basal ganglia) • Dual/multi-tasking • Online fine tuning of motor plans (cerebellum) • Normally doesn’t do a lot with unexpected perturbations (most balance subconcious→lower centers) • Reflexive higher level movement patterns (brain stem and BG) • When the grunts can’t handle things • Conscious control of balance • Cortex focuses priorities and minimizes distractions • While not quick or efficient, the cerebral cortex is vital for planning and dictating the • Any corrective action must take place within 400 msec or a fall occurs. execution of motor plans (also for motor learning) • Fire dept analogy (Richardson et al) • When the boss takes charge—he is not as fast as the workers on the line→more delays and decreased ability to multitask

OKAY, THE KING HAS SPOKEN… NOW WHAT? LOOKING FROM THE OUTSIDE IN… (EXTERNAL FACTORS FOR BALANCE)

• The resultant reactions must be quick and strong • The Environment: • Muscle strength (not mm mass) is tied to balance (Bijlsma, et al, 2013) • Base of support • Not just strength but flexibility is important as well • Surface of interaction • Reactions must be accurate • “Busy-ness” of the environment • An intact coordination system (including the cerebellum) is important too • Amount of light • If the reaction under or overshoots the target, or the accuracy of the reaction is off, then the problem can get worse! • Other internal factors to consider: cardiovascular health, endurance and fatigability, drive and motivation • Hey, what about the external factors???

LOOKING FROM THE OUTSIDE IN… BALANCE IN THE GOLDEN YEARS (EXTERNAL FACTORS FOR BALANCE)

• Evidence established that balance is diminished in • The Demands of the Task: the elderly as compared to younger adults • Simple vs complex (Tsutiya et al, 2015) • Single vs dual/multitasking • This is true even in the absence of disease • Novel or old hat processes! • Time constraints • Effect of others • The key question… Why?

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EFFECTS OF AGING ON BALANCE EFFECTS OF AGING ON BALANCE

• Sensory • Musculoskeletal • Deficits in vision (acuity, contrast, light sensitivity) • Decline of muscle strength and tone • Muscle strength is tied to balance • Presbyopia, macular degeneration, glaucoma, cataract and diabetic • → retinopathy Sarcopenia begins in 40’s with up to 50% decrease in mm mass by the 80’s • Decreased tissue elasticity and flexibility • Loss of hearing/vestibular sense • Diminished bone density • Vestibular hair cell and neuronal degeneration • Arthritic changes in joints (spine as well) (Iwasaki & Yamasoba, 2015) • Changes in spinal posture (Thoracis kyphosis, diminished lumbar lordosis, etc.) directly affects balance • Diminished somatosensation (Drzal-Grabiec et al, 2014) • Distal sensory and central processing issues

EFFECTS OF AGING ON BALANCE EFFECTS OF AGING ON BALANCE

• Neurological/Cognitive • Cardiovascular • Delayed reaction times (remember the 400 msec rule!) • Impaired endurance • “Rigidity of thought” • Decreased distal circulation • Memory storage and recall problems • Edema • Diminished ability to multitask • Low cognitive status associated with poor balance and more falls • Diminished brain perfusion (Stijntjes, et al, 2015) • Autonomic issues • If neuromuscular system is impaired, neurocognitive system must be sharp! (orthostatic )

EFFECTS OF AGING ON BALANCE ENVIRONMENTAL/SOCIAL FACTORS

• Urinary issues • Is home accessible and hazard free? • Urinary frequency and UTIs are an independent • Is community accessible and hazard free? risk factor for falls in the elderly (Soliman et al, • Does home modification reduce fall risk? 2016) • How active is the patient? (the more active the • Pelvic floor weakness in women higher the risk for falls) • Prostate issues in men • How is the patient’s social network? • (diuretics, etc.)

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THE “PSYCH” FACTOR COMMON DISEASE PROCESSES IN THE ELDERLY

• Depression—is a direct risk factor for falls! • Neurological: Diabetes, , CVA, TBI, SCI (cervical stenosis/fall combo), Neurodegenerative (PD and MS) • Taylor et al, 2014 • (Timar et al, 2016; Suttanon et al, 2013; Hoang et al, 2014) • Fear of • Musculoskeletal: osteopenia/porosis (BMD <2.5 SD from avg), OA/RA/DJD (obesity related?), gout • Leads to decreased mobility and increased falls • Cardiovascular: Diabetes, Cardiac diseases (CHF, cardiomyopathy, etc.), Atherosclerotic diseases (PVD, CAD, • Risk factors: hx of falling, female, older CVA) • Falls Efficacy Scale: >70=fear of falling, >80=increased risk of falls • Activities-specific Balance and Confidence Scale (ABC): <67=falls risk • Vestibular: BPPV (over 1% of elderly (Van der Zaag-Loonen et al, 2015) and up to 17% of those referred to PT for • Up to 50% of those with hip fractures have FoF unsteadiness (Ritchie et al, 2015)) • Cancer: mm weakness, debility, neurological deficits, ROM deficits (example: mastectomy affecting shoulder ROM) (Huang et al, 2014)

PAIN AND BALANCE WHEN HEALTHCARE MAKES THINGS WORSE…

• Medications and balance • Causes: musculoskeletal (OA, DJD), neurological (neuropathy, radiculopathy, central pain • The elderly are often on a multitude of medications that increase their risk of falling (>3-4 meds syndromes), systemic (cancer) indicates high risk): • How does it affect balance? • Antihypertensives—one of the biggest culprits! (Tinetti et al, 2014). • Pain effects on mm activation • Sedatives • Limits on range of motion (hurts to move) • Muscle relaxers (benzodiazepines) • Decreased activity level→debility and • Anticonvulsants weakness • Antipsychotics • Bello et al, 2014; Patel et al, 2014 • This can be due to poor communication among various providers (physicians and pharmacists) or lack of communication between patients and their physicians regarding complications and side effects.

WHAT HAPPENS WHEN YOU LOSE IT? FALLS STATS

• Falls definitions • Falls lead to over 800,000 hospitalized patients per year, and brain are most common. • Miriam Webster definitions (2017): • Hip fractures • To descend freely by the force of gravity • 25-75% do not return to PLOF • To leave an erect position suddenly and involuntarily • Are at a higher risk for more falls • 15% die while at hospital • Healthcare definitions: • 33% do not live 1 year s/p fx • An unplanned descent to the floor (or extension of the floor, e.g., trash can or other equipment) with or without . All types of falls are included, whether they result from physiological reasons or environmental reasons. (ANA guidelines, 2005) • Fall injuries are among the 20 most expensive medical conditions. Medicare costs are over $31 billion/year (2015) • CDC, 2017 • Patient definitions: • Oftentimes, a fall isn’t counted unless it results in some kind of injury! • Bottom line: • Falls are way too common, and can lead to serious injury or even !

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WHAT CAUSES FALLS? WHAT CAUSES FALLS?

• Key fall risk factors • Fear of falling • Bottom line: • Intrinsic factors: • Extrinsic factors: • A person has a very short time frame (400 msec) to correct balance or a fall will occur! • Age • Home hazards (, bathroom accessibility, • History of falls poor lighting, obstacles, flooring) • Muscle weakness • issues • Bottom bottom line: • and balance problems • Improper use of assistive device • Just like with balance, falls are multifactorial and so are difficult to predict and even harder to prevent • Poor vision (Richardson, 2017) • Postural hypotension (cdc.gov, 2017) • Chronic disease (OA, PD, DM, CVA, incontinence, dementia)

SO WHAT CAN WE DO ABOUT IT? ASSESSMENT

• Education on Prevention (and when to know intervention is needed) • History • History of falls—details (what specifically were they doing, what were the circumstances, etc.), PLOF (gradual decline or • A targeted screening, appropriate referral, and comprehensive medical/therapy evaluation abrupt?) • An individualized multifaceted treatment plan that focuses on most impactful deficits • Questionnaires (ABC, DHI, fall risk awareness (FRAQ), etc) • Medical history (Robertson & Gillespie, 2013; Stubbs et al, 2015) • Neuropathies can cause major balance issues • A multidisciplinary approach to care • Cardiac or arterial disease can lead to syncopal episodes • Blood pressure conditions can lead to (usually due to meds, but can also be dehydration or other issues) • Regular post-care follow up and screening • Vestibular dysfunction (Meniere’s, BPPV, hypofunction, etc) increases fall risk • Misc disease processes (such as those discussed before) • Medication review

ASSESSMENT ASSESSMENT (WHAT’S WRONG WITH THIS FORM?) (WHAT’S WRONG WITH THIS FORM?)

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ASSESSMENT ASSESSMENT

• Systems Testing • Systems Testing • ROM and flexibility • Muscle Strength • Ankle dorsiflexion: sit to stand (STS) ability and gait progression; also causes posterior LOB • Hip abductors: frontal plane stability • Hip flex: ability to lean forward in STS • Hip extensors: sagittal plane stability, • Hip ext: gait speed and upright posture STS from lower surfaces (see early knee ext and • Spinal motion: dynamic balance use of UE, posterior lean) • Knee flexion: STS ability and descending stairs • Knee extensors: last half of STS, stability during walking, stairs, stooping to pick up objects • Knee extension: will affect upright posture and stride length in gait • UE range: ability to correct LOB and catch self • Ankle muscles: overall balance, gait speed (triceps surae), may see tripping (anterior tib)

ASSESSMENT ASSESSMENT

• Systems Testing • Balance specific measures • Vision: visual fields, acuity (Snellens), use of (bifocals?), hx of visual issues? (cataracts, • Basic tests: Romberg, Sharpened Romberg, SLS macular degeneration, etc.) • Tinetti—not a very good test but works well with lower level patients who need to • Somatosensory: protective sensation (10g monofilament), proprioception/vibration use an assistive device. BEWARE VARIATIONS! (Köpke & Meyer (2006) • Vestibular: balance with head turning, s/s of BPPV or other vestibular issue? DGI/FGA testing • Berg—”gold standard” but only assesses certain aspects of balance (not gait) (Muir • Vestibular loss is correlated with advanced age et al, 2008) • BPPV is common in the elderly (but often underdiagnosed) • However, one study suggests that CNS involvement may be most common cause of “dizziness” in elderly • DGI or FGA—great higher level tests that measure aspects of balance during gait , fallers (Schlick et al, 2015) can use an assistive device as well (Wrisley et al, 2004 and Nilsagård et al, 2014)

ASSESSMENT ASSESSMENT

• Balance specific measures • Balance specific measures • Timed Up and Go—good, quick and easy test for gait and transfer ability, but • Bottom Lines questionable in isolation for fall prediction (Barry et al, 2014; Criter & 2016) • Every test measures something different • BEST test—gives a LOT of info but takes a long time (Mini-BEST and Brief-BEST are (may need more than one test to see all better) (Marques et al, 2016) aspects of balance) • 5xSTS—good measure of transfer ability and strength (Teo et al, 2013) • Don’t rely on scores—there are no hard • Gait Speed—fastest walkers fall outdoors (>1.3m/s) and slowest walkers fall indoors numbers for fall risk! (<0.6m/s): (Quach et al, 2011) • Example: Muir et al study on the Berg (2008)

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Summary of conditions for the Clinical Test of Sensory ASSESSMENT Interaction and Balance.

• Sensory Organization • How does the patient use this information? • Modified CTSIB, computerized dynamic posturography • Visual dependence increases stiffness (open loop) and fall risk • Balance strategies: • Ankle strategy—should kick in 1st on normal surface. If delayed or absent, suspect distal sensory deficits • Hip strategy—used 2nd but will be used more than ankle during activities with small base of support. If delayed or absent, suspect vestibular deficit • Stepping strategy—last attempt to correct balance. Will be delayed or absent with motor problems (weakness, CNS deficits, etc.) • Important to assess (shows reactive balance vs. predictive): BESTest • Predictive of falls! (Bunce et al, 2016) Su C et al. Am J Occup Ther 2010;64:443-452

ASSESSMENT ASSESSMENT

• Functional Assessment • Observe patient during activities: standing up, quiet stance, walking, multitasking • Gait: not just walking straight path! How do they do with: • To assess neurocog: • Compliant surfaces • Reaction time testing • Obstacles • Low light or low contrast areas • https://www.humanbenchmark.com/tests/reactiontime • Turning, backwards, sideways • https://www.justpark.com/creative/reaction-time-test/ • May try to reproduce conditions of previous fall • https://faculty.washington.edu/chudler/java/redgreen.html

ASSESSMENT ASSESSMENT

• To assess neurocog: • To assess neurocog: • Reaction time testing • Reaction time testing • Stroop • Stroop—selective attention test

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End 13 10 ASSESSMENT 8 9 I D B 4

• To assess neurocog: 3 Begin • Reaction time testing 7 1 5 • Stroop H C • Trails B 12 G

A J

2 6 L E F K 11

ASSESSMENT INTERVENTION

• To assess neurocog: • Reaction time testing • Stroop • Trails B • Instruct the patient to draw a line connecting numbers and letters in the following sequence: 1 to A to 2 to B to 3 to C… etc. • Start timer and help patient make corrections during test • Scoring • Average = 75 seconds • Deficient > 273 seconds • Other considerations: Dual-tasking (Talking while Walking Test)—will see dramatic fall off in one or both tasks when performed simultaneously https://barbellnation.wordpress.com/2013/05/22/crossfit-not-fit/

LOW RISK FALLERS MODERATE RISK FALLERS • PREVENTION! • Walking • Must start with comprehensive balance assessment! • At least 20-30 minutes/day of moderate to vigorous activity 3-5x/week (ACSM) • Intervention must be multifactorial and targets risk factors (generic or poorly staffed interventions • Use assistive devices when necessary actually increase falls!) • Practice variety: vary speed, terrain, gait • Includes progressive dynamic balance training patterns • Rehabilitation over compensation • Inclines, stairs, STS for hip extensors • Must be of sufficient intensity and duration: at least 3x/week, minimum 1h/week for 40h total (Power and • Flexibility: Stretching, Yoga, Clifford, 2013; Gunn et al, 2015) • Extracurricular activities: dancing, golf, biking

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HIGH RISK FALLERS (FRAIL) SPECIFIC INTERVENTIONS

• Comprehensive assessment • Prioritize most impactful impairments and address them: • Multidisciplinary team approach • Strength • ROM • Focused interventions: strengthening 1st, then • Sensory organization and reweighting progressive balance ex • Adaptability and speed of reactions • Compensation vs. rehabilitation • Neurocognitive training: dual and multitasking • Focus on balance over walking—better use of time and resources! • Aerobic exercise—improve cardiovascular endurance

• BOTTOM LINE—a tailored multifaceted approach to addressing balance typically works best (Cadore et al, 2013 and Vieira et al, 2016)

SPECIFIC INTERVENTIONS SPECIFIC INTERVENTIONS

• Strengthening: • Strengthening demo video • Ex for muscle endurance, strength, and power • Overload Principle - work at 30-80% 1RM (or 3x8-10 reps at moderate difficulty) • Task specificity—open vs closed chain ex→which exercise mimics a component of the actual functional task? • Strength training can improve static postural control (Sedliak et al, 2013) BUT… Improved static postural control does not necessarily translate to better balance (Yu et al, 2013) • Also focus on speed and accuracy with strength training • Resistance training is SAFE: 9 studies have shown no adverse affects for most subjects undergoing training from 10% to 100% 1RM exercise (most progress from around 30% to around 80%) (Cadore et al, 2013)

SPECIFIC INTERVENTIONS SPECIFIC INTERVENTIONS

• ROM: • Flexibility demo video • Balance starts from the ground up—so flexibility issues down low affect balance more dramatically, but inflexibility up the chain can impair balance as well. • Common exercise interventions: • Runner stretch for tight heel cords (pt must WB to stretch gastroc/soleus!) • Thomas stretch or prone lying for tight hip flexors • Spinal movement (rolling, reaching, etc.): especially rotation (Pts c PD are notoriously tight) • Stretching ex can improve TUG and FR scores: (Saiki et al, 2015). • Accommodate contractures? Yes, but only temporarily to make them safer in the interim (heel wedges)

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SPECIFIC INTERVENTIONS SPECIFIC INTERVENTIONS

• Traditional Balance Training: • Fallacy of this approach: • Romberg standing eyes open and closed • #1—We focus too much on maintaining balance, but falls are more about what people do when they actually • Tandem stance LOSE their balance! • SLS • Carty, C. P., Cronin, N. J., Nicholson, D., Lichtwark, G. A., Mills, P. M., Kerr, G., ... & Barrett, R. S. (2014). Reactive stepping behaviour in response to forward loss of balance predicts future falls in community-dwelling older adults. Age and • Standing on foam ageing, afu054. • Standing with perturbations • #2—Life is much more variable than standing! We move in all kinds of ways, and move our feet around more • Standing with upper extremity tasks (balloon vball, catching/throwing, etc.) than we realize—Interventions should encompass real world chaos (no one improves on a task they never practice) • Focus: maintaining balance in standing position

SPECIFIC INTERVENTIONS SPECIFIC INTERVENTIONS

• Tenets of Balance Reeducation: • Tenets of Balance Reeducation: • Capitalize on and work what the patient has: • Capitalize on and work what the patient has: • Intact sensory systems (visual, vestibular, somatosensory) • Intact sensory systems (visual, vestibular, somatosensory) • Intact motor systems (speed, power, accuracy, adaptability) • Visual: How do they do with low contrast or low lighting? High contrast or busy environments? Limited visual field? • Speed: Patient may be able to successfully complete a task, but how long does it take to complete? • Vestibular: How do they do with head movement and quick changes of direction? Can they coordinate visual tasks while • Gait speed as an outcome measure moving? • Timed trials • Somatosensory: How do they do on different surfaces? Over and around obstacles? Different footwear? Limited base of • Power: adequate force to make corrections quickly and accurately support? • Functional strength training with speed and accuracy in mind • Sensory Integration: If they are dependent on one particular modality (usually visual) focus on activities to refocus attention • Accuracy: Placement of feet (and sometimes hands) needs to be spot on (no under or overshooting) to other areas: • Timed target stepping—”stepping stones,” balance beam • Limit the availability of sensory modality they are dependent on (i.e. blindfold, low light,etc. for visual dependence) • Perturbation training • Perform activities to force accuracy—use of BWS harness? • Combine challenges for different modalities (no more than 2 at a time though unless they are very advanced!)

SPECIFIC INTERVENTIONS SPECIFIC INTERVENTIONS

• Tenets of Balance Reeducation: • Tenets of Balance Reeducation: • Capitalize on and work what the patient has: • Capitalize on and work what the patient has: • Intact sensory systems (visual, vestibular, somatosensory) • Intact sensory systems (visual, vestibular, somatosensory) • Intact motor systems (speed, power, accuracy, adaptability) • Intact motor systems (speed, power, accuracy, adaptability) • Intact cognitive systems (problem solving, multitasking, demands of the task) • Intact cognitive systems (problem solving, multitasking, demands of the task) • Setup tasks that require planning and problem solving (obstacle courses, finding objects or locations, solving a puzzle while • Take home point—you can improve what they have but you probably can’t recover what they’ve already lost! navigating environment) • Tailor activities to mirror the real world • Multitasking is often difficult for our patients (glass of water analogy) • Mimic real life scenarios (time constraints, environmental barriers, etc.) • Walking While Talking Test and TUG-cognitive • Challenge patients to their limit (and beyond?) • Combine cognitive tasks with physical tasks (walking and multiplication) • If a patient doesn’t lose their balance, how can they learn to regain it? • Combine 2 or more physical tasks (dialing phone number or texting while walking backwards) • • Setup the task to challenge the limits of the patients’ physical and mental abilities! (Fringe play) Depending on task, the patient should always be “flirting with disaster” (with you guarding of course!)

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SPECIFIC INTERVENTIONS SPECIFIC INTERVENTIONS

• Anticipatory Balance vs. Reactive Balance • Balance exercise demo video

SPECIFIC INTERVENTIONS SPECIFIC INTERVENTIONS

• Recalibrating balance back to vertical • Balance recalibrating demo video(s) • Visual tilt has a modest effect on SVV—argument for tilting visual environment to opposite to "trick" someone into leaning that way? (Corballis et al, 1978)—prism glasses. • Balance can be "recalibrated" to different points by biasing system with accentuated tilt in desired direction (Mathevon et al, 2016). • Ideas for exercise: • Standing and walking on/across incline (can use treadmill for this) • Using BWS harness or tilt table to tilt patient away from direction of lean • Encourage weight shifting and reaching away from direction of lean • Using solid physical objects (wall, table, etc.) to have patient lean on away from direction of lean • Once patient starts to compensate can make more challenging by: • Having him work towards the affected side (reaching or walking that direction) • Bringing more attention to the lean by using weight or resistance to pull that direction (weighting limb, walking away from ex band, therapist pull, weight sled, etc.)

SPECIFIC INTERVENTIONS SPECIFIC INTERVENTIONS

• Newer technologies: • Exercise and balance: • Popular consoles: • Overall fitness is tied to balance: Lee & Cho (2014). Effect of stationary cycle exercise on gait and balance of elderly women. • Nintendo Wii and Wii Fit • In neurological and frail patients, exercise helps balance (including dual task): (Zanotto et al, 2014). Effect of exercise on • Xbox Kinect dual-task and balance on elderly in multiple disease conditions. • Playstation Move • Exercise options: • VR vs. AR • Studies have been very popular (especially with • Tai Chi (Tousignant et al, 2013 and Cadore et al, 2013)—probably the most evidenced-based lay exercise for helping balance (Nintendo Wii): • Yoga (Yang et al, 2015) • Hung et al, 2014 • Pilates (Hyun et al, 2014 and Televski et al, 2015) • Barcala et al, 2013 • Aquatics (Fisken et al, 2015) • Cho et al, 2014 • (Pretty much anything to get patients moving and increase HR!) • Bieryla & Dold, 2013

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SPECIFIC INTERVENTIONS SPECIFIC INTERVENTIONS

• New technologies: • Misc • Video games can assess balance and makes training more • Joint approximation using weights improves balance (10% BW): (Dhiman et al, 2014) fun: (Pisan et al, 2013 and Van Diest et al, 2013) • Video games are being developed specifically for elderly • Visual control is tied to balance--saccadic eye training improves balance: (Bae, 2016). fitness and balance: (Nawaz et al, 2014) • Galvanic stimulation can improve balance (with an aftereffect of a couple of hours): (Fujimoto et al, • Silverfit: http://silverfit.com/en/products/silverfit-3d-camera 2016). • www.saebo.com/saebovr • Bracing? (Kent et al, 2016). Effects of foot and ankle devices on balance, gait and falls in adults with • The evidence is still out on video games for balance sensory perception loss. training (study quality is low (Alhasan et al, 2017)), although the overall weight of evidence is positive: (Zeng • Shoe width? (Yamaguchi et al, 2015) et al, 2017)

THE FOLLOW THROUGH: HEP AND BEYOND OTHER INTERVENTIONS

• Home exercise programs can work if implemented correctly: (Taylor et al, 2017) • Home Modifications (Robertson & Gillespie, 2013) • • HEP compliance: Other Adaptations—Transportation services (OATS), reliance on social support, home relocation (senior living, , NH)? • Patients need to feel like they can make a difference in their health: (Chen et al, 1999) • Referral for: • Patients need to perform exercises correctly: (Schoo et al, 2005) • Vitamin D supplementation (Shuler et al, 2014 and Robertson & Gillespie, 2013) • Videos are no better than brochures: (Schoo et al, 2005) • Medication review by physician (Tinetti et al, 2014) • 2 is better than 8: (Henry et al, 1999). • Telephone Calls Make a Difference in Home Balance Training Outcomes: (Light et al, 2016)

FALL PREVENTION PROGRAMS FALL PREVENTION PROGRAMS

• Keys to a successful prevention program • Otago Exercise Program—reduced falls in New Zealand by 46% (Exercise based) • Multifaceted approach • http://www.acc.co.nz/PRD_EXT_CSMP/groups/external_providers/documents/publications_promoti • Exercise on/prd_ctrb118334.pdf • Education: ex and lifestyle, home/community needs • KAAOS—reduced falls by 26% in Finland (Multifaceted) • Home safety assessment • Medication management • Palvanen, et al. (2014) • Vision screening/intervention • NFPP—reduced falls by 39% in the Netherlands (Multifaceted) • Multiple disciplines involved as needed—therapists, physician/nursing, social work/case management, psych, etc. • Smulders, et al (2010) • Adequate training and organization of providers • Make sure everyone is on same page, referrals set up • For a full compendium of fall prevention programs: • Community buy-in • https://www.cdc.gov/homeandrecreationalsafety/falls/compendium.html • Does the program match the needs/desires of target population? • Is it easily implemented and maintained?

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BARRIERS TO SUCCESS

• Public perception! QUESTIONS? • MOST PEOPLE ARE IGNORANT OF FALL PREVENTION STRATEGIES (EVEN THOSE WHO GO THROUGH PT): (Lam et al, 2015) COMMENTS? • Patients also tend to not see the benefits of interventions for themselves, even CONCERNS? when they can see it for others: (Haines et al, 2014) CRITICISMS? • Solution→Education (Health screenings, “Fall clinics”, education campaigns, brochures/articles/blogs, etc.)

THANK YOU.

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