2010 Sure Step

A Multi-Factorial Falls Intervention
An Evidence Based Prevention
Program
Sunday, April 15, 12

Session 20
October 23, 2010
Concordia University Wisconsin
Mequon,WI
2010 WOTA CONFERENCE

Sandra Ceranski, MS, OTR/L
Carol Dickert, MS, OTR/L, LPTA
Carol Pociecha-Palm, MRE, OTR/L

LEARNING OBJECTIVES
• Discuss the theoretical base of Sure Step as a multi-factorial falls
intervention.
• Discuss background and main elements of the Sure Step
algorithm.
• Practice administration, scoring and interpretation of selected
screens
• Discuss the clinical application and reimbursement perspectives in
participant’s practice settings. © Sandra Ceranski, MS, OTR

• Multi-factorial falls intervention developed 2001
• Jane Mahoney, MD and Terry Shea, PT
• Adapted from evidence based guidelines published
by AGS, BMS and AAOS
SURE STEP IS...
© Sandra Ceranski, MS, OTR

SURE STEP INCLUDES
• In home fall risk assessment using detailed
algorithm
• Follow-up in home visit with recommendations
• Referrals and recommendations for client,
Physician/Primary Care and Therapists
• Monthly phone contacts for 12 months

ALGORITHM
“A step-by-step procedure for
solving a problem”
(Merriam-Webster online)

• 25 risk factor “areas” to measure through screening/
assessment processes
• Medication, risky behavior, environment, vision,
cognition, balance, gait and other factors
• Triggers based on measures WFL or not WFL
• Recommended “Action to Take”
• Recommendations for “Health Professionals”
ALGORITHM

STEP BY STEP PROBLEM SOLVING
Risk Factor Area Triggers Action to Take &
Recommendations
• Medications/OTC
• Benzodiazpenes
• Sleepers
• Antidepressants
• Neuroleptics
• Allergy Med
• Use of
medication
• Class
• Education on risk
• Alternatives
• Discuss with MD
• ↓ dose as able
• Avoid

Mahoney, et al. 2005
POTENTIAL COST SAVINGS
Nursing
Home Costs
$176/day was cost of NH in WI in 2004
Cost savings from reduced NH stay by 50 days = $8,800/person
Hospital
Stays
$15,000 avg. cost of older adult in WI 2002
$15,000 cost savings by averting one hospitalization per year
Cost of Fall The average cost of a prevented fall has been estimated at $1,900
Effective
select
45 % fewer falls for person with MMSE <28 with live in caregiver

POSTURAL STABILITY
A fall, or not falling, is not an
event...it’s a process
© Carol Dickert, MS, OTR, PTA

PROCESS INVOLVES 3
COMPONENTS
• Sensory Input
• Central Processing
• Effector Output

COMPONENTS OF
POSTURAL CONTROL
©2006 Sure Step Training Manual
Mahoney, Shea, Schwalbe, Cech
Musculoskeletal
Strength
Biomechanical
Effector Output
Cognition
CNS Pathways
Medications
Central Processing
Visual
Vestibular
Proprioceptive
Sensory Input
Environment

SENSORY INPUT
“Our Sensory Systems take in Information from the
environment regarding our body’s position in space,
then sends that information to the Central Nervous
System (the Spinal Cord and Brain).”

CENTRAL PROCESSING
The brain takes the information that is received from
the Sensory Input...processes that information...and
determines an appropriate response.

EFFECTOR OUTPUT
Nerves carry information regarding the appropriate
response from the brain to the muscles & joints.The
muscles respond by making changes/responses that
sustain balance & equilibrium for the Body.

WHAT CAN GO WRONG?

SENSORY INPUT
VISION

VISION
As we age ourVisual Acuity changes.
We need more time to adjust to darkness.Young adults
can adjust to the dark almost instantaneously. Older
adults require up to 15-20 minutes for the eyes to adjust
to the dark

VISION
Depth Perception - Signiﬁcantly different visual
ability in the eyes will cause unsafe depth
perception. Problems with depth perception
cause falls risk, especially on stairs.

VISION
Multifocal Lenses - Bifocals or Trifocals. Progressive
lenses impair depth perception on stairs if you don’t
look through the correct level in the lense.This
problematic if the person cannot perform adequate
cervical ﬂexion due to limited ROM/Pain.

SENSORY INPUT
VESTIBULAR SYSTEM

VESTIBULAR SYSTEM
The inner ear allows a person to
sense motion & the position of
the head in space.

DISORDERS OF THEVESTIBULAR
SYSTEM
•Meniere’s
Disease
•Labyrinthitis
•Benign
Positional
Vertigo
•Ear Infections
•Tumors
•Trauma

VESTIBULAR PROBLEMS MAY BE
WORSE
• in crowded areas
• when turning the head
• in the dark
• rocking, spinning and/or up-down
movement

SENSORY SYSTEM
PROPRIOCEPTION

PROPRIOCEPTION
The Somatosensory System consists of motion, position
& pressure sensors in the joints, muscles & skin.These
sensors provide tactile & positional information to
enable us to sustain postural control/balance.

CAUSES OF PROPRIOCEPTIVE
PROBLEMS
• Peripheral Neuropathy
• Loss ofVibratory Sense
• Loss of Light Touch & Joint Position Sense

COGNITION
CENTRAL PROCESSING

COGNITION
• As cognition declines, the incidence of falls increases. There
is a direct correlation between decreased cognitive abilities
and increased falls & injury.
• The higher levels of cognition – executive functions are key
in the patient’s abilities in safety judgment/ safety
awareness.
• As executive function declines, patients engage in more risk
behaviors during their ADLs/ IADLs/ MRADLs.

CENTRAL NERVOUS SYSTEM
PATHWAYS

DISEASE THAT IMPEDE CNS
PATHWAYS
• Cerebrovascular Accident
• Brain infections or abscesses
• Multiple Sclerosis
• Parkinsons Disease
• Degenerative Syndromes (i.e.
alcoholism)
• Depression (↓attention to the
environment, slowed cognitive
& motor reactions)
• Head Trauma
• Heart conditions (i.e. CHF,
Abnormal Rhythms, ↓Blood
ﬂow to the brain)

MEDICATIONS
Psychotropic medications affect balance because
they decrease alertness to the environment and
slow the rate of central processing.

MEDICATIONS
When a young adult takes a medication, half of that
medication remains in their body 1 day later. When an
older adult takes a medication, half is in their body 1
WEEK later. This causes a signiﬁcant cumulative effect.

EFFECTOR OUTPUT

MUSCULOSKELETAL
Unsafe Balance/ Stability - The
Sure Step Program administers
several balance & gait tests.

INADEQUATE
EQUILIBRIUM AND
RIGHTING REACTION

EQUILIBRIUM
The body’s ability to sustain the
center of gravity at midline

The body’s ability to return the
center of gravity to midline/ right
itself when displaced beyond its
limits of stability.
RIGHTING REACTIONS

INADEQUATE EQUILIBRIUM
AND RIGHTING REACTIONS
• Tripping Falls
• Slipping Falls
• Reaching (Center of Mass)
Falls

LIMITS OF STABILITY
• “Limits of Stability” is how far the body can sway
without taking a step.
• Moving the Center of Gravity beyond these limits
may cause falls during ADLs/ IADLs/ MRADLs.

• 8° Forward
• 4° Backward
• 8° Laterally Left &
Right
LIMITS OF STABILITY

STRENGTH
• Decreased hand strength is one indicator of
increased risk for falls.
• Lower extremity strength is essential in preventing
falls. All mobility skills (sit to stand, transfers,
ambulation, stair climbing, etc.) require adequate LE
strength.

BIOMECHANICAL
• Improper footwear is a fall risk.
• In general the best is a ﬁrm, thin soled shoe with
good support and good tread on the bottom.
• Slippers, stocking feet, and bare feet should be
avoided.

FOOT DEFORMITIES
• Tendonitis
• Plantar Fasciitis
• Heel Spurs

ABNORMAL GAIT PATTERNS
• Decreased Step Height & Length
during Gait Cycle
• Asymmetrical Gait (Example:
“stiff” hip/ knee w/ hiking to
clear ﬂoor)
• Lack of Continuity during Gait
• Antalgic (Painful) Gait Pattern
• Trendelenberg (Gluteus Medius)
Gait Pattern
• Hemiplegic Gait Pattern
• Parkinsonian Gait Pattern
• Scissors Gait Pattern (due to
Spastic Hip Adductors)
• Foot Drop Gait w/ ↓Ability to
Dorsiﬂex the Ankle

Sure Step Algorithm ©2006 Sure Step Training Manual
Mahoney, Shea, Schwalbe, Cech

Measurement Areas to
distinguish
Action to Take &
Recommendations
2 or more falls in year prior
1 fall & history of near falls or
imbalance
Acute infection related to falls
(UTI, pneumonia, etc.)
Medical conditions: Stroke, LE
arthritis, LE fractures &
Neuropathy
If ≥ fall risk
factor
Educate patient and caregiver
regarding # risk factors
means greater risk
Caution ill or med. changes
Environmental changes
Use assistive device
Notify Physician
FALL RISK FACTORS
© Carol Pociecha-Palm, OTR

distinguish
Action to Take &
Recommendations
Current Assistive Equipment
CURRENT ASSISTIVE EQUIPMENT

distinguish
Action to Take &
Recommendations
Residence:
Senior apartment
Apartment (not senior housing)
Live alone or with someone
(describe)
RESIDENCE

distinguish
from
measurement
Action to Take &
Recommendations
Fall History
1. ______________________
2. ______________________
3._______________________
If Fall Ask patient to discuss with
physician
Educate patient and cargiver
Tripping/slipping falls
Falls with movement
Falls with rising
FALL HISTORY

distinguish
Action to Take &
Recommendations
“How confident are you that you
can do___without falling?” (LC,
FC...) Risky: Y; N
Meal Prep
Shopping
Bathing
Walking on snow and ice
Any potentially
risky IADL/ADL
Any non-risky
IADL/ADL with
“Not at all
confident”
Education
Task specific modifications:
increased supervision
home modification
task avoidance
meals on wheels
IADL’S, MOBILITY ADL’S AND
CONFIDENCE

distinguish
Action to Take &
Recommendations
Pets
Poor day or night lighting
Nocturia
Bifocals, trifocals, progressive
lenses
If patient does any
behavior
Recommend OT for
modifying behavior &
techniques with ADL’s/IADL’s
Nocturia (decrease evening
water intake, no caffeine after
5:00 pm
RISKY BEHAVIORS

distinguish
Action to Take &
Recommendations
What type(s) of physical activity do
you get?
Describe amount & type:
TYPE OF PHYSICAL ACTIVITY

distinguish
Action to Take &
Recommendations
Do you have any pain with walking,
doing exercises, or performing
normal activities?
Rate pain 0-10 _____
Describe:
Current treatment for pain?
Past treatment for pain?
If yes Ask patient to discuss with
physician
Recommend PT/OT for pain
management
Discuss and encourage types
of exercise that patient is
already doing to alleviate pain
PAIN

distinquish
Action to Take &
Recommendations
During the past month, have you
often been bothered by:
1. Little interest or pleasure in
doing things?
2. Feeling down, depressed or
hopeless?
If >Yes to 1 or 2 Advise patient to discuss with
MD, as it slows recovery and
raises fall risk.
Notify MD-phone call is
warranted if patient answered
“yes” to both questions #1
and #2 on the Two-Question
Depression Scale.
Two-Question Depression Screen

Measurement Triggers Action to Take &
Recommendations
VAMC SLIMS Examination
What is the highest level of
education completed?
High School Education?
Less than High School?
If score < 27 and
has high school
education
or < 25 if less than
high school
education
Discuss with patient and
caregiver regarding raised fall
risk, need for supervision, etc.
Need for supervision
Consider further evaluation
for cognitive impairment and
treatment as appropriate
Consider evaluation for
reversible causes of cognitive
impairment B-12 etc.
VAMC SLUMS

distinguish
Action to Take &
Recommendations
Vitamins and Diet
1.Calcium (Supplement & Diet)
2.Vitamin D
3.Multivitamin
4.When was your last Bone
Mineral Density Test?
If Calcium < 1200
mg/day
If Vitamin D < 800
iu/day
Recommend daily elemental
calcium intake of 1200 mg/day
Recommend 1 multivitamin
per day
Recommend daily intake of
800-1000 iuVitamin d per day
as recommended in 2008.
VITAMINS AND DIET

MEDICATION
Recommendations
• Sleep Medication
• Antidepressants
• Anxiety
• Antipsychotic
• Allergy Med/spray
• Dizziness
• Neuropathic pain
• Bladder control
• Alcohol use
• Use
• Dose
• Class
• Educate on risk
• Avoid or minimize
• Lowest does
• Alternatives
• Discuss with MD

VISION
Recommendations
• Eye Exam
• Type of lenses
• Use with walking
• Vision test
• Visual ﬁeld
• <20/40
• Difference
between eyes
• No visit in past
year
• Multi-focal
lenses
• Good lighting
• Environment
• Mobility device
• Caution stairs, curbs
• See eye doctor
• ReferVision & OT
• Single vision lenses
• Cataract surgery

FOOT DEFORMITY
Recommendations
• Observe with shoes off
• Hammer toes
• Bunions
• Abnormal
• Refer to podiatrist for
balance and gait
• Extra depth shoes
• Ankle foot orthotics

ANKLE ALIGNMENT
Recommendations
• Observe during standing and
walking with shoes on and off
• Not corrected
with shoes on
• Refer to Podiatrist or PT

FOOTWEAR
Recommendations
• High heels
• Floppy slippers
• > 1 in. heels/soles
• Large tread
• Yes to any • Avoid
• Firm thin soles
• Podiatrist

VIBRATION
Recommendations
• Lie down
• 128 Hz tuning fork
• Toe and ankle with eyes closed
• If absent • Education
• Cane or AD
• Extra caution
• Diagnosis

ORTHOSTASIS
• A patient with Orthostatic Hypotension may
experience Syncope (pass out), or may fall due to
Orthostatic Hypotension without fainting.
• To measure, use Blood Pressure Cuff & Stethoscope
to get Blood Pressure reading. Record Pulse Rate.

ORTHOSTASIS
• “Normal” Blood Pressure is 120/80. “Normal” Pulse
Rate is 60 beats/ minute.
• Record Blood Pressure & Pulse Rate after patient lies
supine for 3-5 minutes. Then standing position for 1
minute. If the Systolic (Top) number drops by >20
points, Orthostasis is problematic.

ORTHOSTASIS
Alert the Physician:
" Systolic reading is too high >180
" Systolic reading is too low <100
" Diastolic reading is too high >90

SURE STEP ALGORITHM
• Let’s learn by doing
• What do you want to learn
more about?
• What could you incorporate
into your practice?

2010 Sure Step

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