Transcript Document

Beyond Balance:
Evidence Based Practice Enhancing Quality of
Life in the Geriatric Patient
Jenny Zimney, MPT, GCS
[email protected]
Northwest Rehabilitation Associates
1380 Liberty St. SE
Salem, OR 97302
(503) 371-0779
7/7/2015
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Beyond Balance:
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What factors create
safety and balance?
Can I really impact
the frequent faller?
Can fear of falling
be overcome?
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Course Objectives:
Following today’s session you will be able to:
1.
2.
3.
Choose and implement the appropriate
functional scale for their patient status and
setting.
Develop objective measurable treatment
interventions and goals based on the functional
scales used.
Discuss the rationale and purpose for each
functional scale presented.
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Course Objectives cont’d:
4.
5.
6.
Quantify a geriatric patients balance, fear of
falling and fall risk using the functional scales
presented.
Identify reliable reimbursement and marketing
options for fall prevention programs in your
community.
Make a greater impact on reducing falls in your
community!
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Systems of Balance
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Balance and Motor Planning:
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What is my plan/objective?
What am I feeling?
What am I going to do about it?
Was this successful last time?
What is my plan this time?
Can my body do this (or) do this in time?
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Allum et al 2002 J Phys
Changes in Postural Control with Age
Results:
With perturbation on sway board
Younger = Trunk rolls toward
from perturbation (uphill)
Older = Trunk rolls away from
perturbation (downhill)
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Sensory Systems
Vision
Somatosensory
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Vestibular
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Age Related Changes: Vision
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↓ visual acuity
Impaired dark adaptation
↓ response to peripheral field visual stimuli
↓ contrast sensitivity
Difficulties with accommodation
Abnormal visual perception
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Age Related Changes: Vestibular
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Loss of hair cells in semicircular canals
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Calcification in cupula
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“Thinning” of vestibular afferent axons
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Age-Related Changes:
Somatosensory
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10-15% ↓ nerve conduction velocity
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↑ Sensory detection thresholds
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↑ Central processing time
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↑ latency of automatic postural responses
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Age related changes:
Efferent System
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↑ Active muscle stiffness
↓ Muscle force and power generation
capacity
↑ Variability of contraction amplitudes for
proximal/distal muscles of a synergy
↑ of trials to adapt strategy for
perturbation
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Age Related Changes: Etiology
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Normal changes associated w/ aging
Decrease in physical activity/stimulation
Disease states: Diabetes, PVD, CVA,
vestibular dysfunctions, macular
degeneration
OR
Learned non-use
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Vision
Task
Requirements
Ambient
Conditions
Reaction
Time
Environmental
Terrain
Vestibular
Medications
Somatosensory
The Equilibrium
Of
Balance
Muscular
Power/
Endurance
ROM
Hx of
Balance
Reactions Temporal
Factors
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Attention/
Cognition
Physical
Load
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Comorbidities
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Common medications related to
falls:
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Benzodiazapines (Valium, Ativan)
Sedatives (Benadryl, Buspar)
Hypnotics (Xanax)
Antipsychotics (Thorazine, Haldol)
Antidepressants (Elavil)
Antihypertensives (Lopressor, Catapress)
Antianxiety (Librium)
Diuretics (Lasix, Diuril)
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Balance Review: More thoughts…
 Environmental
Demands
 Cognition/Attentional
 Self-Efficacy/Fear
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Demands
of Falling
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Environmental Demands and
Balance/Mobility
36 older adults self reported trip log and
videotaped weekly (tracking 8 environ
dimensions)
Results: Temporal (speed), physical load,
terrain and postural transitions (head
mvmt) distinguished those w/
disabilities, 1/2 as many activities and
had to be accompanied.
(Shumway-Cook A, et al. Phys Ther. 2002;82:670-681)
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Attentional Demands:
Static vs. Dynamic Equilibrium
6 healthy young subjects (20-30 yo)
Tested reaction time to auditory cue with sitting,
standing upright (broad and narrow base,
walking (SLS and DLS)
Standing > sitting; Walking > sit or stand; SLS >
DLS
Conclusion: Balance control w/in gait is not
automatic.
Lojoie, Teasdale, Bard, Fleury. Exp Brain Res. 1993;97:139-144.
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Attentional Demands of Obstacle
Negotitation
15 older adults vs. 15 younger adults
 Testing reaction time to auditory cue with
walking level and over foam block when in
SLS
Results: Pre-crossing and Crossing were =
in older adults
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Brown, McKenzie, Doan. J Geron. 2005;60A(7):924-927
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Attentional Demands:
Dual-task Methodology:
1. Limited Central Processing Capacity
2. Task performance requires part the
limited capacity within the CNS
3. If performing 2 tasks and that capacity is
exceeded, 1 or both tasks can be
disturbed.
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Voluntary Step and Cognitive Task
66 healthy elderly vs. healthy young adults
 Tested voluntary stepping on force plate
single task and w/ modified Stroop test
Results: Older adults with
Single task: 42-52% slower step initiation
Dual task: 190-256% slower, 41% no
reaction
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Melzer, Oddsson. JAGS. 2004;58(8):1255-1262
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Fear of Falling Influences Gait
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95 com-dwell older adults
Gait parameters: speed, stride length,
step width, double limb support time
In fearful group, speed was slower, stride
shorter, step width larger and double limb
support time was 6% longer.
Chamberlin ME, Fulwider BD, Sanders SL, Medeiros JM. J Geron: Med Sci. 2005;60A:9:1163-1167
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Fear of Falling:
Predisposing Factors
6. No Emotional Support
5. Sedentary Lifestyle
4. Chronic Dizziness
3. Fall history w/ in previous year
2. Vision > 50% impaired
1: Age > 80 Anxiety Trait
Murphy, Dubin, Gill. J Geron 2003;58A(10):M943-947.
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Assessing Balance: Falls History
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How often do you lose your balance, i.e.
slip, trip or stumble?
When was your most recent fall?
Did the fall occur inside or outside?
How did the fall occur?
Were you injured?
Were you dizzy when you fell?
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Why use Functional Testing?
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Evidence-based
Demonstrate skill
Establish Goals
Guide to treatment
Objective measure of
progress
Prediction of future
events
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Types of Reporting
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Self-Report**
Clinician observation
and rating**
Equipment-based
testing
**Focus of Functional Test presented
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Which is best?
Self-Report
Clinical Observation
Proxy-Report
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The Activities-specific Balance
Confidence Scale (ABC)
Developed by Powell and Myers with input from 15
clinicians and 12 older outpatients to quantify
fear of falling
 Type of Information: Self Report
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Components: 16 items of varying difficulty
rated on 0-100% scale
Equipment needed: Paper and pencil
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Time to Complete Test: 5-10 minutes
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The Activities-specific Balance
Confidence Scale (ABC)
Scoring:
> 80 = high functioning
older adult (I com. Dwelling)
50-80 = moderate level of
functioning (Chronic Health
Conditions or ALF)
< 50 = low physical
functioning (Home care)
Myers AM et al, J of Gerontol:Medical Sci, 1998
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The Activities-specific Balance
Confidence Scale (ABC)
Strengths:
 Inexpensive
 Self Testing
 Examines community
mobility
 Variety of situations
and environments
assists in treatment
and goal setting
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Weaknesses:
 Cannot use w/
significant cognitive
impairment
 Imagination needed if
not regularly
performed
 Very high ceiling
 Nearly no floor effects
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Modified Falls Efficacy Scale (mFES)
Adapted from Tinetti’s FES to quantify fear of
falling
 Type of Information: Self Report
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Components: 16 items of varying difficulty
rated on 0-100% scale
Equipment needed: Paper and pencil
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Time to Complete Test: 5-10 minutes
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Modified Falls Efficacy Scale (mFES)
Scoring:
Items are scored from 0 to 10.
Total the ratings (possible range = 0 –
140) and divide by 14 to get each
subject’s mFES score.
Scores of < 8 indicate fear of falling, 8 or
greater indicate lack of fear.
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Modified Falls Efficacy Scale (mFES)
Weaknesses:
Strengths:
 Cannot be used w/
 Inexpensive
significant cognitive
 Self Testing
impairment
 Assesses indoor and
outdoor situations
 More realistic
activities then ABC
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ABC
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VS
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mFES
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Timed “Up and Go”
Developed by Richardson and Podsiadlo to assess
basic mobility skills in older adults
 Type of Information: Clinician Observation and
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rating
Components: One Item- stand, walk 10 ft, turn
come back and sit down.
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Equipment needed: Stopwatch, Chair (46cm)w/
arms (65 cm)
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Time to Complete Test: 1-2 minutes
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Timed “Up and Go”
Scoring:
 >30 sec people that are more dependent,
unable to climb stairs, require AD, help
with transfers, dependent in most
activities
 <10 sec freely independent
 <20 sec( I) transfers, I toilet, able to
climb most stairs, go out alone
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Timed “Up and Go”
Strengths:
 Can use assistive
device
 Quick, easy,
inexpensive
 Incorporates most
aspects of mobility
 Sensitive to change
 Not diagnosis
dependent
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Weaknesses:
 Not usable for nonambulatory patients
 Ceiling – not
challenging for
community dwellers
 Must be able to
follow directions
 Only a few aspects
of balance are
challenged
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Normal Values of Balance Tests in
Women Aged 20-80
456 women in 6 age cohorts
Tests: TUG, Step, FR, LR
Results:
Linear change with Step and TUG
FR started to decline in 40’s
LR started to decline in 30’s!!!!!
Isles, Choy, Steer, Nitz JAGS 2004;52(8):1367-1372.
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Berg Balance Scale
Developed to measure balance of the older adult
in a clinical setting
 Type of Information: Clinician observation
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Components: 14 items of everyday tasks
rated on 0-4 scale
Equipment needed: Ruler, Watch, 2 standard
chairs, footstool or step, object
Time to Complete Test: 15-20 minutes
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Berg Balance Scale
Specifics of testing:
 No assistive device
can be used
 Must be able to stand
unsupported
 Forward reach w/
fingers outstretched
(36% cannot do this)
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Berg Balance Scale
Scoring:
 41-56 low fall risk
 21-40 medium fall risk
 0-20 high fall risk
Additionally
 > 45 safe,
independent
ambulator
 < 36 fall risk near
100%
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Berg Balance Scale
Strengths:
 Challenging for
healthy, Com. Dweller
 Wide range of
difficulty and patients
 Reliable for PD or CVA
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Weaknesses:
 Cannot use assistive
device
 Ceiling effect for high
level functioning
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Physical Performance Test
Developed to assess function in community
dwelling older adults
 Type of Information: Clinician observation and rating
 Components: 3 Versions (7,8,9 item tests) rated on
0-4 scale
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Equipment needed: Stopwatch, paper & pen,
bowl and 5 kidney beans, spoon, coffee can,
heavy book, jacket or sweater, penny, 25-foot
walkway, flight of stairs
Time to Complete Test: 15-20 minutes
Reuben, Siu. JAGS 1990;38(10):1105-1112
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Physical Performance Test
Specifics of testing:
 Timing is from the
word “Go”
 Incorporates stair
climbing
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Physical Performance Test
Scoring:
 < 15 predictor of
recurrent falls
**Treatments, goals
and other referrals
can be designed from
each item.
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Physical Performance Test
Strengths:
 Can use assistive
device
 High ceiling
 Measure multiple
areas of function
 Responsive to change
w/ functional training
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Weaknesses:
 Requires equipment
 Scale is ordinaldecreased sensitivity
to change
 May fail to challenge
multiple facets of
balance
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Physical Performance Test
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Schmidt et al:
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Predictive of frail elderly dropout rates in
exercise program (JAGS 2000;48(8):952-960)
Brown et al:
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Differentiates Mild to Moderate Frailty
(J Geron 2000;55A(6):M350-355.)
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Dynamic Gait Index
Developed by Shumway-Cook and Wollacott to
assess likelihood of falling in older adults
 Type of Information: Clinician observation and rating
 Components: 8 facets of gait, 0-3 scale
 Equipment needed: box, 2 cones, stairs, at least
25 ft walkway
 Time to Complete Test: 15 minutes
Shumway-Cook A, Woollacott A, Motor Control Theory and Practical Applications.
Williams & Wilkins, 1995
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Dynamic Gait Index
Specifics of the test:
 Test gait at different speeds
 Stepping over and around obstacles
 Gait w/ head turns (horizontal and
vertical)
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Dynamic Gait Index
Scoring:
< 19 related to falls
 > 22 safe
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Dynamic Gait Index
Strengths:
 Can use assistive
device
 Examines 8 facets
of gait including
speed, head turns
and over obstacles
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Weaknesses:
 Only looks at gait
 Not tested in many
populations
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Whitney, Hudak, Marchetti 2000
Studied 247 patients with vestibular
disorders and found:
DGI effective to ID fall risk with older
and younger adults with vestibular
disorders
J Vest Research 2000;10(2):99-105
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DGI
=
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Functional Gait
Assessment
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Functional Gait Assessment (FGA)
Developed by Wrisley et al. to increase the
sensitivity of DGI.
 Type of Information: Clinician observation
and rating
Components:
 Equipment needed: 2 boxes, 2 cones,
stairs, at least 25 ft walkway, stop watch
 Time to Complete Test: 15 minutes
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Functional Gait Assessment (FGA)
Strengths:
 Can use assistive
device
 More sensitive to
change than DGI
 Walking backward
 Dual-task
 Environmental barrier
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Weaknesses:
 Only looks at gait
 No scores published
yet
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6-Minute Walk Test
Developed to assess exercise tolerance in cardiopulmonary patients
 Type of Information: Clinician observation and rating
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Component: Gait distance
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Equipment needed: Stopwatch, sphygmomanometer,
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Time to Complete Test: 6-10 minutes
stethoscope
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6-Minute Walk Test
Specifics of testing:
 Encourage patient to
not talk during test
 Take vital signs pre
and post
 Patient can take
standing rests
 Termination of testing
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6-Minute Walk Test
Scoring:
 Few published
norms
 < 1000 ft (300m)
indicative of
morbidity w/in 6
months in heart
disease
 Median w/ healthy
older adults
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Mean distance by age:
60-69 years: male 572m,
female 538m
70-79 years: male 527m,
female 471m
80-89 years: male 417m,
female 392m
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6-Minute Walk Test
Strengths:
 Can use assistive device
 Sensitive to change w/
exercise training
 Safe due to patients selflimiting during test
 Easy to perform, little
equipment needed
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Weaknesses:
 Must be able to stand
and/or walk 6
minutes
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Kristjansdottir et al 2004
Compared 6-MWT to Limited Graded
Exercise Test:
6-MWT effectively identified
cardiopulmonary concerns as did graded
test.
Conclusion: Good test for cardiopulmonary
rehab…….Conditioning????
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Timed Stands
Designed to assess strength, mobility and
endurance
 Type of Information: Clinician observation
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Component: Repeated standing up from seated
position
Equipment needed: Stopwatch, chair or mat
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Time to Complete Test: 1-2 minutes
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Timed Stands
Specifics of testing:
 Can be time to complete 5 reps, reps
completed in 30 or 60 seconds.
 Patient is allowed to use any means
necessary for standing up. (record need
for UE’s)
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Timed Stands
Scoring: 30 second timed stands
Normal
Range *
60-64 65-69 70-74 75-79
80-84
85-89
90-94
Men
14-19 12-18 12-17 11-17
10-15
8-14
7-12
Women
12-17 11-16 10-15 10-15
9-14
8-13
4-11
*Normal range of scores is defined as the middle 50 percent of each age group.
Scores above the range would be considered “above average” for the age group and
those below the range would be “below average”.
Jones CJ, Rikli RE, Beam W. Res Q Exerc Sport. 1999;70:113-119
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Timed Stands
Scoring: 5 second timed stands
Sit to Stand Time (Seconds) by Age and Gender
75-79
80-84
85-89
90+
Total
Men
12.1 (5.4)
12.9 (5.5)
13.7 (7.2)
17.2 (8.0)
12.8 (5.9)
Women
12.2 (4.1)
13.4 (5.6)
14.1 (6.5)
15.1 (6.5)
12.9 (5.1)
(SD) = standard deviation
Lord, S.R. et al. J Gerontol A Biol Sci Med Sci. 2002; 57A(8):M539-M543.
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Chair Stands as a Measure of LE
Strength in Sexagenarian Women
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47 women performed 5STS, 30STS, Isokinetic
testing of hip, knee and ankle
Results:
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5STS: Ankle PF, Hip Flex & Knee Ext.
30STS: Ankle PF
But both only moderate predictors of LE strength.
Other factors: sensorimotor, balance, psychological
McCarthy et al. J Geron. 2004;59A(11):1207-1212.
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Other Functional Assessments
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Short Physical Performance Battery – tandem
stance, 5STS, gait speed
(Guralnik et al. J Geron. 1994;49(2):M85-M94)
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UAB Life-Space Assessment – Assesses mobility
in 5 designated environments
(Peel et al. Phys Ther. 2005;85:1008-1019)
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NWRA Obstacle Course – UE dual task w/ gait
over obstacles
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Clinical Decision Making
Tests are chosen based on:
1. Facet of gait, balance or mobility noted to
possibly be deficient
2. Possible need for referral
3. To support care plan, treatment, skilled
therapy, or establish objective goals
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More on
Clinical Decision Making
Individual patient needs guide assessment choice
but setting distinctions may include:
Acute care, ALF, SNF, LTC & HH:
TUG, 6MWT, Timed Stands, PPT
Outpatient: BBS, ABC, mFES, PPT, DGI, TUG,
Timed Stands, 6MWT
Community Outreach/Screening: TUG, Timed
Stands, ABC, mFES
NOTE: These are only generalities, do NOT limit the choice of test
based on setting.
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What do we do now?
What treatments work?
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What therapeutic interventions work?
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Strength and Conditioning
Flexibility
Speed/power training
Dual-task/attention training
Functional training
Cognitive Training
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Land vs. Aquatic Exercise
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11 older adults (ALF and outpatient) Berg
Balance Scale <47/56
Comparable exercises on land and in
water. 2x/wk x 6 weeks.
Results: Significant improvements but no
difference between H2O and land-based.
Douris et al. J Ger PT. 2003;26(1):3-6.
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Eccentric Work
LaStayo et al. compared cardipulmonary
rehab with LE eccentric resistance in frail
elderly.
Results: Eccentric work group showed:
↓ in TUG (16.65 to 11.96 seconds)
↑ in Berg (49.7 to 53.4)
LaStoya et al. J Geron. 2003;58A(5):M419-424.
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Innovative treatment ideas:
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Dynadiscs (static vs. dynamic balance)
? One-legged stance
Corner vs. Countertop
Eyes closed or not?
Lite Gait
Dual tasking
Backward gait
Speed training
Conditioning and strengthening
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Fall Prevention and You!
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Falls Free: Promoting A National Falls
Prevention Plan
V15.88 History of Fall, new diagnosis
codes to be implemented on October 1,
2005
Falls Free Program
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Case Study #1: Earl
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78 yo male 5 days post prostate surgery
onset of LE weakness
PMH CABG, “CVA’s”, Seizures
PLOF: Highly active, Lived I, Walked dog
in park daily, Phase III cardiac rehab.
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Case Study #2: Julia
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82 yo female fell 6/04 w/ L hip fx w/ THA
No falls since but is “very afraid”
Meds: Plendil, Diovan, Lexipro
PMHx: CVA 11 years ago, HTN
7/7/2015
J Zimney MPT, GCS
77
Case Study #3: Bill
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75 yo male w/ hx 4-5 falls in last 6 mos.
Latest fall, “reached to floor and just
rolled”.
PMHx: MVA w/ TBI & R LE fx ’60, R RTC
repair, C5-6 discectomy, CABG x 4, NIDDM
Wife and dau assist prn
7/7/2015
J Zimney MPT, GCS
78
Case Study #4: Shirley
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64 yo female w/ severe onset of dizziness
that lasted 3-4 days, no just “very
unsteady”.
PMHx: dizziness onset 5 yrs ago,
Hypothyroidism, Breast CA
Meds: Synthroid
No Health Insurance
7/7/2015
J Zimney MPT, GCS
79
Case Study #5: Myrt
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84 yo female 7/4/04 reaching to close
trunk when struck by car, fell w/ pelvic fx.
3 weeks in nursing home
Sister reports multiple falls
c/o back pain, using quad cane, FWW
PMHx: nothing significant
Meds: Zetia, Multivitamin, Naproxyn
7/7/2015
J Zimney MPT, GCS
80