On the final day of CSM, I started the day off with “What’s New in Prescribing Balance Intervention Programs” from Debbie Epsy, Ann Reinthal and Tanvi Bhatt.
Balance is becoming my jam, so I wanted to make sure I wasn’t missing anything.
First, I learned there are 3 categories of fall causes:
1. Internal: the clumsy ones that trip over nothing, or shift their own weight way too far outside their base of support to where they can’t control it anymore.
2. External: Here we have the trip or stumble on something, like a curb or rug (1/3-1/2 of falls are these), being hit or bumped by someone or something, sudden loss of an external support and slipping on a slippery surface
3. “Other”: unknown causes and collapses/sudden loss of consciousness
People that fall tend to have decreased stride length, walking speed, increased step width and poor standing balance. Those folks that are aware of the deficits they have will change their gait patterns to look like this because they are scared. They will also just not be up and around much. Which leads to further deconditioning, making them even more likely to fall. This is where a therapist must step in. Hopefully before they come see to me in inpatient rehab with a broken hip.
To assess a person’s fall risk, the CDC’s STEADI is a good tool to start with. It is designed so a lay-person can start the process themselves by asking themselves 3 questions and find out if they need to have professional help with their balance. It also provides a check list for primary care providers to double check items in a patient’s health to ensure falls are not a problem. The items the health care provider needs to check include:
— falls history
— review medications
— orthostatic hypotension and other cardiovascular causes black out type falls
–patient’s home and community for fall hazards
— continence assessment
— balance confidence or patient’s perceived abilities
— physical exam of sensation, vision, motor systems
— balance performance
When selecting your balance outcome measures, remember to consider what ICF domain your measure is in and the purpose of your measure. You’ll want one that predicts fall risk (and shows improvement in fall risk with treatment) and one that tells you WHY the person is falling to guide your clinical decision making. The more common performance tests are the BEST/mini-BEST and the Physiological Balance Profile Approach (PPA) (which I’ve never heard of. I’m surprised the speaker didn’t mention Berg or TUG here. Maybe it was in the final presentation and not in the preliminary one we got for handouts.) Then for the cognitive aspect of balance, there is the Trail Making Test and the Stroop Tests. For self-reports, there’s the Activity Specific Balance Confidence Scale and the Fear of Falling Avoidance Behavior Questionnaire (in the appendix of the article).
Now, how do we dose balance interventions? Dosage was a big topic at IV Step too. First we’ll get back to the FITT principle (Frequency, Intensity, Time, Type).
Balance intervention types fall into 2 main categories
— conventional: Impairment based– the typical strength, endurance, flexibility/ROM, sensory, motor control interventions; mixed– explicit (strengthening exercises with weights + functional balance activities like OTAGO) and implicit (balance strategies– weight shifting–, functional strengthening like sit to stands, gait); proactive functional training; reactive functional training
— contemporary/alternative: perturbation training (hooking up the patient in a harness and purposefully knocking them over on treadmill, slippery surface, pushing them, etc.); mind-body (tai-chi, yoga), dance; video games; virtual reality; dual-tasking
Intensity is really hard to gauge in balance and very subjective. So one of the presenters, Debbie et. al. had the Rate of Perceived Stability recently researched and published in 2015.
Good enough for me! Now, where are we shooting on there? That I don’t know. I would *guess* 4-6 if you’re without a harness or up to 8 if you’re in a harness would be a good place to work in, simply because that’s where I shoot on the cardiovascular RPE.
Frequency and time depends on the type. For OTAGO, the participant does all the exercises 3 times a week (about 30 minutes) and goes for a walk 2 times a week (30 minutes). For dance, 45 minutes- 2 hours, 1-4 times a week (really broad, I know.) With virtual reality, you’ll need 10 or more sessions of 60 minutes or more to see minimal changes. In perturbation training you need just 1-2 good slips every 3 months to get your reactions up to par. The rest don’t have research established frequency or time. (This area is ripe for you to jump onto the research wagon!)
The big take-aways I got here were the perturbation training as I had never heard of that, the RPS scale and that in order to get the good research results that mind-body interventions can provide, the instructor really needs to have extensive practice themselves and have a certification in that form of treatment. Which is why I’m seriously considering continuing on with the tai-chi course I took and getting certified. I already practice tai-chi and yoga myself, so…. Decisions, decisions.