Balance in elderly
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This presentation will give you an out look about Balance Assessment & Intervention Strategies - Elderly

This presentation will give you an out look about Balance Assessment & Intervention Strategies - Elderly

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  • 1. Phinoj. K. Abraham IInd MOTh Student All India Institute of Physical Medicine & Rehabilitation, (AIIPM&R) Mumbai
  • 2.  Balance: General Concepts & Considerations  Balance in the Elderly: Special Concerns • Age Related Changes • Assessment • Intervention Strategies 2
  • 3.  Definition • Balance is defined as a “complex process involving the reception and integration of sensory inputs, planning and execution of movements, to achieve a goal requiring upright posture.” (Nashner L, 1994) • It is the ability to control the COG over the BOS in a given sensory environment. (Nashner L, 1994) 3
  • 4.  Posture • The term posture is often used to describe both Biomechanical alignment of the body as well as Orientation of the body to environment  Balance impairment may resulting from, • Neurological conditions • Musculoskeletal conditions • Psycological conditions. 4
  • 5. 5
  • 6.  Earlier studies are, • Based on neurophysiologic principles. • Focused on Reflexive & Reactive equilibrium responses .  Recent studies • Incorporated other relevant systems  In a Systems model or system approach to dynamic equilibrium. 6
  • 7.  “…Balance is the result of interactions between the PERSON individual, task and environment” ENVIRON MENT TASK 7
  • 8.  Within the PERSON…  Sensory inputs & processing system. (b/w E & P)  Motor planning & execution system. (b/w P & T)  Influence of other systems. • Sensory input Environment Person • Sensory processing & motor planning • Execution of task Task 8
  • 9. VISION VESTIBULAR SOMATO SENSORY CENTRAL NERVOUS SYSTEM MUSCULOSKELETAL SYSTEM PHYSICAL EQUILIBRIUM 9
  • 10. It includes… Peripheral sensory reception. A. i. Somatosensory ii. Visual iii. Vestibular  Dysfunction leads to impaired rendering of sensory information's to brain. Central sensory perception. B. Multi Sensory reweighting - “Upweightage” &“Downweightage” of sensory information(s). •  Dysfunction result in to “sensory conflict” 10
  • 11. It includes…  Central motor planning & control • Depends on  Attention, Intention & Motivation  Peripheral motor execution- through bilateral Joints & muscles. • Factors influencing are,  ROM  Muscle strength  Endurance  Musculoskeletal evaluation is significant here. 11
  • 12. Cognitive & behavioral factors… • Attention • • • • • • • Cognition Judgment Memory Depression Emotional liability Agitation Denial of impairment. 12
  • 13.  Balancing is always accomplished in an environmental context.  Some environmental factors influencing balance are, • Gravity • Surface conditions • Visual environment • Intention • Task choice 13
  • 14. 14
  • 15.  Postural Control Inputs  Somatosensory systems • • • • - cutaneous receptors in soles of the feet - muscle spindle & Golgi tendon organ information - ankle joint receptors - proprioreceptors located at other body segments  Vestibular system • - located in the inner ear • - static information about orientation • - linear accelerations, rotations in the space  Visual system • - the slowest system for corrections (200 ms) 15
  • 16.  This includes… A. Reflexes  Vestibulo-occular Reflex (VOR)  Allows the coordination of eye & head movements.  Vestibulospinal Reflex (VSR)  It helps to control movement & stabilize the body. (via. Righting like labyrinthine, optical, body on head righting)  The VSR permits stability of the body when the head moves and is important for the co ordination over the trunk over the extremities in upright posture. 16
  • 17. B. Automatic postural responses     Ankle strategy Hip strategy Suspensory strategy Stepping & reaching strategy • When the COG is outside of the BOS, a strategy is required (shift, step or stumble) is required to prevent a fall. (INHERENT FALL PREVENTION) • Strategies are automatic • Occur 85 to 90 msec after the perception of instability is realized 17
  • 18.  Used when perturbation is: • Slow • Low amplitude  Contact surface firm, wide and longer than foot  Muscles recruited distal - to proximal  Head movements in-phase with hips 18
  • 19.  Used when perturbation is: • fast • large amplitude  Surface is unstable or shorter than feet  Muscles recruited proximalto distal  Head movement out-of phase with hips 19
  • 20.  Forward bend of trunk with hip/knee flexion  May progress to a Squatting position  COG lowered 20
  • 21.  Used to prevent a fall  Used when  Perturbations are: • Fast • Large amplitude • Or when other strategies fail • Base of Stability (BOS)  Moves to “catch up” 21
  • 22. C. Anticipatory postural adjustments  Aim: to counteract the destabilizing consequences of a Voluntary movement.  Failure to produce this adjustment – increases the risk of falling 22
  • 23. D. Volitional Postural Movements  Self initiated disturbance of the COG to accomplish a goal. 23
  • 24. Basic Principles of Postural Control - Summery 24
  • 25. 25
  • 26. The Sensory System  With Aging: • Vision may decrease in acuity, contrast sensitivity, and depth perception. • The vestibular system may undergo agerelated changes, resulting in dizziness and unsteadiness. • There may be a decrease in proprioception and vibration. 26
  • 27. The Central Processing System  Aging may result in: • • • • Slowing of sensory information Slowing of nerve conduction velocity Increased postural sway Increased incidence of co-contractions  Cognitive Area • High level Sensory Adaptation  Decreased ability to shift from the use of one sensory input to other for poster control • Attention  Increased attention required for the Postural Control  Poorer performance in Dual Tasks (in Cognitive & postural tasks) 27
  • 28.  The Effector System  Aging • • • • may result in: Decreased muscle strength Decreased ROM and flexibility Increased “stiffness” of connective tissue Aging may result in cardiovascular changes 28
  • 29. - 30% fear falling1  35%-40% of people 65+ fall each year 2  Those who fall are 2-3 times more likely to fall again3  10%-20% of falls cause serious injuries4  20%  In India, • Incidence of fall is 14% (History of a single fall in the last 6 months) • M:F = 68%:32% 1. Vellas BJ, Age & Aging, 1997; Friedman SM, JAGS, 2002 2. Hornbrook, Gerontologist, 1994; Hausdorff, Arch Phys Med & Rehab, 2001 3. Tinetti, New Eng J Med, 1988; Teno, JAGS,1990 4. Sterling, J Trauma-Inj Infection & Critical Care, 2001 29
  • 30. 2 classifications, • Classification 1 1. Intrinsic (internal) Risk factors 2. Extrinsic (external) Risk factors 3. Acquired Risk factors • Classification 2 1. Modifiable Risk Factors 2. Non-Modifiable Risk Factors 30
  • 31.  Intrinsic (internal) risk factors • Examples- Age, osteporosis, vision loss, dementia  Extrinsic (external) risk factors: • Examples- Medications, footwear, assistive devices, environment  Acquired risk factors: • Examples- Facility or hospital admission due to health change or decline (new environment), delirium due to illness, increased disability due to injury 31
  • 32. Modifiable risk factors • Examples: Muscle weakness, poor balance, exercise level, medications, environmental lighting, footwear Non-modifiable risk factors • Examples: Age, chronic conditions, disability, dementia, vision loss 32
  • 33. 33
  • 34. is “an appraisal or evaluation of a patient’s condition, based on clinical & laboratory data, medical history, and the patient’s account of symptoms”  Assessment  Taber’s cyclopedic medical dictionary., 18th ed. p 16  The system approach is a useful approach for the assessment of balance in elderly • A comprehensive assessment of balance function from the system perspective would include examining the older adult performing a range of balance tasks under a variety of contexts. 34
  • 35.   Underlying Components of balance control to be assessed include, • Muskuloskeletal • Sensory • Motor & • Cognitive Balance tasks to be assessed includes • Self Report Measures • Quiet standing (static) • Active standing (dynamic) • Sensory manipulation • Vestibular • Functional scales • Dual task & Multiple Task 35
  • 36. The Activities-specific Balance Confidence (ABC) Scale • Description of the Instrument  The Activities-specific Balance Confidence (ABC) Scale is a 16-item scale; each item is rated from 0% (no confidence) to 100% (complete confidence). • Form of instrument:  Questionnaire/ Survey • Reliability Validity = Good 36
  • 37. 37
  • 38.  Refers to test in which the client is standing and the movement goal is to hold still. (i.e. Static Balance)  Perturbations may or may not be applied.  Examples are, • • • • • • Double Limb Standing Single Limb Stance (SLC)/ Unilateral standing Tandem Stance Romberg Test Sharpened / tandem Romberg One legged stance tests (OLSTs) 38
  • 39.  Procedure • Both legs must be alternatively tested • Difference b/w sides are noted  The client stands on both feet and crosses the arms over the chest, then picks up one leg and hold it in neutral and the knee flexed to 900.  The lifted leg may not be pressed in to the stance leg.  Five 30 sec trials are performed for each leg  Max. score is 150 for each leg  Interpretation • Normal young subject are able to stand for 30 sec • Gehlsen and Whaley found that a one-legged stance test distinguished elderly fallers from non-fallers. 39
  • 40.  Refers to test in which the client is standing and the movement goal involves voluntary weight shifting.  Examples are, • Functional reach test • Multidirectional reach • Sit-to-stand, Sit down • Reaching movement • Different walking tasks (turning, head rotation, on beam, stop and start etc) • Limits of stability : it is the farthest distance in any direction a person can lean (away from the mid line) with out altering the original BOS by stepping, reaching, or falling 40
  • 41.  This was developed for use with older adults to determine risk for falls.  Procedure • The client stands near a wall with feet • • • • parallel A yard stick is attached to the walls in shoulder (acromion) height The client is asked to make a fist & raise the arm nearest the wall (without touching) to 90° of shoulder flexion The examiner notes the fist (3ird MC head) on the yard stick. The client is then asked to lean forward as far as possible, & the examiner notes the end point. 41
  • 42. • Beginning position is subtracted from end position of the fist on the yardstick.  Interpretation: Score is available  Comments:  Simple single task test, easy to administer, Quick screen  High degree of agreement rates (reliability inter .98 intra .92)  FR is affected by age and height (i.e. anthropometric characters).  Studies shown that this test is useful for fall prediction  Limitation: it measures sway in only 0ne direction.  Less sensitive to illustrate the clinical improvement. 42
  • 43.  This test measures how far an individual can reach in the forward, backward, and lateral directions.  Procedure • For backward reach, the test position is the same as FR • For lateral reach, the client faces away from the wall and reaches to sides (to right and left side) • 1 practical trial is allowed before the start of 3 trial 43
  • 44.  Uses altered surface & visual conditions to determine how well the CNS is using and reweighting sensory input from postural control.  Examples are, • Sensory organization test • Clinical Test of Sensory Interaction on Balance (CTSIB) 44
  • 45.  The SOT uses a computerized, movable force plate and movable visual surround to alter the surface and visual environment systematically.  It is used to determine the effectiveness of an individual to utilize different sensory inputs.  It examines body sway during three 20-second trials under each of six sensory conditions are performed  Components: • Moving platform (sliding or tilting) • A moving visual surround screen 45
  • 46.  Test conditions are, • C1: Eyes Open, Stable Surface (EOSS) • C2: Eyes Closed, Stable Surface (ECSS) • C3: Visual Conflict with Moving Surround, Stable • • •   Surface (VCSS) C4: Eyes Open, Moving Surface (EOSS) C5: Eyes Closed, Moving Surface (ECSS) C6: Visual Conflict with Moving Surround, Moving Platform (VCSS) Test condition 1 provides accurate somatosensory, visual, and vestibular information & is the baseline reference Each of the other 5 conditions increasing the level of sensory conflict & postural difficulty. 46
  • 47.  Interpretation • Posturography equipment provides a printed result • Ratio comparison provide information regarding reliance on one system over another • EMG – to know about muscle activity & recruitment.  Comments • SOT is reliable and valid scale • Normative data is available. 47
  • 48.  It is a clinical version of the SOT that does not use computerized force plate.  The concept of 6 condition is remain intact.  A thick foam pad substitutes for moving force plate.  Interpretation • By using a stop watch • Visual gradations.     SCORE 1 : Minimal sway SCORE 2 : Mild sway SCORE 3 : Moderate sway SCORE 4 : Fall 48
  • 49. These tests use various • Visual acuity body & head positions, • Nystagmus eye movement, or  • Visual-vestibular stepping to stimulate or interaction restrict visual, vestibular or somatosensory inputs.  • Oculomotor tests • Vertigous positions Examples are, • Fukuda Stepping Test • Hallpike-Dix Maneuver • Dizziness Handicap inventory 49
  • 50.  It is a vertiginous position test to stimulate the post semicircular canal  Procedure • Moving the patient from a sitting position with the head turned so that the affected ear is 30-45° below the horizontal stimulate post. Canal and may produce nystagmus & vertigo • A +ve result leads to a diagnosis of Benign positional vertigo (BPV) 50
  • 51.  Functional balance, mobility, and gait scales involve the performance of wholebody movement task.  Examples are • Berg Balance Scale • Tinetti performance oriented assessment of gait. • Timed Up and Go Test • Gait Assessment Rating Scale (GARS) • Dynamic Gait Index • Functional Gait Assessment 51
  • 52.  It is a multi task test of 14 balance task (6 static & 8 dynamic)  Focused on, • Maintanance of position • Postural adjustment to volountry movement  Reliability (inter=.98 intra=.99)  Scoring : 5 point ordinal scale with specefic task criteria  Comments • Simple, easy to administer • Client should able to stand • Provide baseline & outcome data; score of 45 or below are predictive of falls in the elderly 52
  • 53. 53
  • 54.  It is a multi task test: have 2 parts • Balance sub test: 9 items (4 static & 5 dyanamic) • Gait sub test : 8 test  Focused on • Maintenance of position • Postural response to perturbation • Gait mobility  Equipment needed • Chair, walk way; patient can use usuan walking aid 54
  • 55.  Scoring • Some items graded can/cannot perform; some 3 point scale with specific criteria  Reliability : inter=.85 Requirements: able to stand & walk independently  Comments • Simple, easy to administer • Provide baseline data; predictive of falls in elderly   > 24 low risk  19-24 mod risk  18> high risk • Limitation: some scoring criteria vague; difficult to detect small changes 55
  • 56. 56
  • 57. 57
  • 58.  It is a single task test: stand up, walk 3 meter, turn around and return to chair  Focuses on = Functional mobility  Scoring • Timed test uses 1 practice/3 trials for average score  Reliability : inter=.99, intra = .98  Requirements : able to stand & walk independently  Comments • Simple, easy to administer • Provides baseline & outcome data: predictive of falls in elderly 58
  • 59.  These are developed to examine the concurrent activities (i.e. cognitive & postural control demands)and divided attention on balance and mobility performance.  Examples are, • Stops Walking When Talks (SWWT) & Walking While Talking (WWT) • Multiple Tasks Tests (MTT) 59
  • 60.  In these tests, clinician asks the client 1 or more questions and observe if the client must stop walking to answer the question(s).  If so the test is positive. i.e. patient have to stop walking to reallocate attention to the cognitive task 60
  • 61.  This is a more formalize test  It include 8 items involving gait plus other cognitive and motor tasks such as carrying a try and avoid obstacle.  Comments for Dual task tests • Reliability & validity are not well established • Disagreement in the literature exist regarding their usefulness. • In clinical use, these are helpful to detect clients with major problems (Sensitivity ?). 61
  • 62. 62
  • 63.  This topic will be discuss under the following headings • Preventive Exercises • Recent Advanced techniques used for balance intervention in elderly from Literatures. 63
  • 64. CDC     Fall Prevention Recommendations Regular exercise Medication review Vision exams Home safety evaluation (Circulation. 2007;116:000-000.) Downloaded from www.circ.ahajournals.org by on May 16, 2010 64
  • 65. 1. 2. 3. 4. 5. 6. 7. 8. Individual risk assessment Regular strength & balance exercise Gait & assistive device training Medication review & management Management of chronic conditions Vision correction Education Home safety improvements WA State Dept. of Health, Falls Among Older Adults: Strategies for Prevention (2002) Centers for Disease Control 65
  • 66.  The intervention strategies that were evaluated for their effectiveness in preventing falls were classified as single or multifactorial strategies and as generic or individually designed. JAGS 49:664–672 MAY 2001–VOL. 49, NO. 5 , ) 66
  • 67.  Among community-dwelling older persons (i.e., those living in their own homes), multifactorial interventions should include: • Gait training and advice on the appropriate use of assistive devices (B); • Review and modification of medication, especially psychotropic medication (B); • Exercise programs, with balance training as one of the components (B); • Treatment of postural hypotension (B); • Modification of environmental hazards (C); and • Treatment of cardiovascular disorders, including cardiac arrhythmias (D). 67
  • 68.  In long-term care and assisted living settings multifactorial interventions should include: • Staff educationprograms (B); • Gait training and advice on the appropriateuse of assistive devices (B); and review and • Modification of medications, especially psychotropicmedications (B).  The evidence is insufficient to make recommendations for or against multifactorial interventions in acute hospital settings 68
  • 69. Exercise 1. 2. 3. Although exercise has many proven benefits, the optimal type, duration and intensity of exercise for falls prevention remain unclear (B). Older people who have had recurrent falls should be offered long-term exercise and balance training (B). Tai Chi C’uan is a promising type of balance exercise,although it requires further evaluation before it can be recommended as the preferred balance training (C) 69
  • 70. Environmental Modification • When older patients at increased risk of falls are discharged from the hospital, a facilitated environmental home assessment should be considered (B). • In a subgroup of older patients, a facilitated home modification program after hospital discharge was effective in reducing falls (Class I). • Otherwise, modification of home environment without other components of multifactorial intervention was not beneficial (Class I). 70
  • 71. Medication Patients who have fallen should have their medications reviewed and altered or stopped as appropriate in light of their risk of future falls. Particular attention to medication reduction should be given to older persons taking four or more medications and to those taking psychotropic medications. (C) 71
  • 72.  Assistive Devices • Studies of multifactorial interventions that have included assistive devices (including bed alarms, canes, walkers (Zimmer frames), and hip protectors) have demonstrated benefit. However, there is no direct evidence that the use of assistive devices alone will prevent falls. Therefore, while assistive devices may be effective elements of a multifactorial intervention program, their isolated use without attention to other risk factors cannot be recommended (C). • Among hospitalized patients there is insufficient evidence for or against the use of bed alarms (Class I). 72
  • 73.  Behavioral and Educational Programs  Although studies of multifactorial interventions that have included behavioral and educational program have demonstrated benefit, when used as an isolate intervention, health or behavioral education does not reduce falls and should not be done in isolation (B)  A structured group educational program among community- dwelling older people did not reduce the number of falls but did achieve short-term benefits in attitudes and self-efficacy (Class I).  Practice guidelines in the emergency department did not alter documentation of falls risk factors, causes of falls, consequences of falls, or the implementation of practice guidelines (Class I). 73
  • 74.  Bone Strengthening Medications • It reduce fracture rates. But not reduce the rates of falls.  Visual Intervention • Fall-related hip fractures were higher in patients with visual impairment.  Footwear Interventions • For Women: Static and dynamic balance were better in low-heeled rather than high-heeled shoes or than the patient’s own footwear. • For men: foot position awareness and stability were best with high midsole hardness and low mid-sole thickness. Static balancewas best in hard-soled (low resistance) shoes. 74
  • 75.  Sensory-Specific Balance Training in Older Adults: Effect on Position, Movement, and Velocity Sense at the Ankle • Results suggest that short-term improvements in velocity sense, but not movement and position sense, may be achieved following a balance exercise intervention PHYS THER Vol. 87, No. DOI: 5, May 2007,Vol. 87, No. 5, May 2007, pp. 560-568  Effects of ballates, step aerobics, and walking on balance in women aged 50-75 years • All three training programs improved dynamic balance, however, step aerobics be better improvements in postural stability or static balance when compared to the Ballates program. 75
  • 76.  Effects of High-Intensity Strength Training on Multiple Risk Factors for Osteoporotic Fractures A Randomized Controlled Trial • High-intensity strength training exercises are an effective and feasible means to preserve bone density while improving muscle mass, strength, and balance in postmenopausal women. JAMA. 1994;272(24):1909-1914. Vol. 272 No. 24, December 28, 1994  An Objective Approach for Assessment of Balance Disorders and Role of Visual Biofeedback Training in the Treatment of Balance Disorders : A Preliminary Study. • Study suggests that visual biofeedback training facilitates appropriate balance strategies and enables in achieving improved postural control. IJPMR 12, April 2001; 25-30 76
  • 77.  Dual task training  Evidence shows that “in physically fit elderly people, cognitive dual tasks influence balance control during walking directly as well as indirectly through decreased velocity” Marianne B et. al  This shows the significance of dual task intervention in this area  The efficacy of Tai Chi Chuan in older adults:a systematic review • There is limited evidence that TCC is effective in reducing falls and blood pressure in the elderly. Family Practice Vol. 21, No. 1 © Oxford University Press 2004 77
  • 78.  Beneficial effect of proprioceptive physical activities on balance control in elderly human subjects • Proprioceptive exercise therefore appears to have the best impact on balance control. Neuroscience Letters Volume 273, Issue 2, 1 October 1999, Pages 81-84  Community-based group exercise improves balance and reduces falls in at-risk older people: a randomised controlled trial • participation in a weekly group exercise programme with ancillary home exercises can improve balance and reduce the rate of falling in at-risk community dwelling older people. Age and Ageing 2003; 32: 407-414 78
  • 79.  Randomised controlled trial of a general practice programme of home based exercise to prevent falls in elderly women • An individual programme of strength and balance retraining exercises improved physical function and was effective in reducing falls and injuries in women 80 years and older BMJ 1997;315:1065-1069 (25 October)  The Effect of Multidimensional Exercises on Balance, Mobility, and Fall Risk in Community-Dwelling Older Adults • Exercise can improve balance and mobility function and reduce the likelihood for falls among community-dwelling older adults with a history of falling. The amount of exercise needed to achieve these results, however, could not be determined from this study. PHYS THER Vol. 77, No. 1, January 1997, pp. 46-57 79
  • 80.  Training Elderly People in Martial Arts Could Cut Their Risk of Injuries from Falls • Training older people in martial arts could cut their chances of suffering broken bones or fractures when they fall, according to experts. Health & Fitness, Science & Technology News April 22nd, 2010 at 10:10 am  Effect of a Gentle Iyengar Yoga Program on Gait in the Elderly: An Exploratory Study • …. yoga programs tailored to elderly adults may offer a cost-effective means of preventing or reducing agerelated changes in these indices of gait function. Arch Phys med Rehabil Volume 86, Issue 9, Pages 1830-1837 (September 2005) 80
  • 81. And remember, falls can be prevented, except falling in love. 81