This document discusses fall risk reduction through balance examination and intervention. It begins by noting that patients' main fear regarding discharge is falling. It then reviews components of balance like somatosensory, visual and vestibular systems. The document provides a quick screening tool to assess medical issues, vision, vestibular function, weakness, sensation and other balance components. Outcome measures like the Berg Balance Scale, Dynamic Gait Index and Timed Up and Go are discussed. A variety of balance interventions targeting static, anticipatory, reactive and protective balance are described. The importance of making interventions functional is stressed.

1. Fall Risk Reduction: Balance Examination & Intervention
Cara Curran: Sacred Heart University Clinical Rotation Summer 2016
What do patients express as their main fears to discharge?
FALLING.
Gait is a sequence of continuous falling followed by continuous reactions to catch ourselves.
Somato-sensory + Visual + Vestibular = Balance
1. Superficial Sensations “Spinothalamic” System- anterolateral system
Light Touch
Sharp/dull
Temperature
Perception Pressure
“Protective Sensation”à Semmes Weinstein 5.07
2. Deep Sensations “Dorsal Column System”- medial lemniscus system
Vibratory Sense 128 Hz
Position sense/Proprioception
Kinesthesia
3. “Combined Cortical Sensory Function”
Traced Figure Identification
Object Identification
Double Simultaneous Stimulation
Two Point Discrimination

2. Fall Risk Reduction: Balance Examination & Intervention
Cara Curran: Sacred Heart University Clinical Rotation Summer 2016
Objectives:
ü How can the rehab and medical staff here work
towards this goal together?
ü How can we better examine balance in this
acute rehab setting?
ü How can we evaluate our findings based on
national norms?
ü How can we develop POC and treatments based
on our findings?
ü How can we progress our patients
collaboratively?
ü How can we make this task functional?!
Deficits/Barriers Quick Screening
Medical Red Flag Screening Polyneuropathy, OH, timing of medication, you all know J
Visual Perception Glasses? CN 1, 3, 5, 6 (tracking)
Vestibular Nystagmus w/ any above CN (smooth pursuits)? CN 8
Differential: Dix-Hallpike: BPPV
Weakness, lack of ROM, tone MMT<3+, Reflexes, hypo/hypertonic, WB precaution?
Sensation/Proprioception Semmes-Weinstein, 1st
Met orientation, Postural Assessment
Scale For Stroke, Functional Reach
Coordination Hand-nose (tremor/dysmetria), heel-shin/drawing square, DGI,
TUG, 4SST
Cognition on attending to task Return-knowledge, clock-drawing
Endurance 2MWT, 6MWT, 10MWT, 5xSTS
Pain Perception NPRS, VAS, WHOQOL
Self-Efficacy PSFS, ABC, Mini-Best

3. Fall Risk Reduction: Balance Examination & Intervention
Cara Curran: Sacred Heart University Clinical Rotation Summer 2016
Outcome Measures Utilizes!
• According to Anderson et al., outcome measures were used for patients with stroke to
determine the most useful in an acute or acute rehab setting
• The following ranked top for diagnosing and categorizing patients, developing a plan of
care, interventions, d/c recommendations, family education, professional comfort and
preference, evidence based, and time sensitive:
o FIMà you’re all experts J
o BERG
§ Stroke: 45/56= functional ability
• 41/56= cut off for fall risk
§ Elderly: <45= individual may be at
greater risk of falling
• <40= 100% fall risk
§ Parkinson’s: Average= 40.2
o 6MWT: MDIC
§ COPD: +54 meters
§ Geriatrics and Stroke: +50 meters
§ SCI: -0.10 m/s
o TUG
Examination/Outcome Measures:
Postural Assessment Scale For Stroke
• 12 items for individuals with stroke regardless of their postural competence
• Sensitive for first 3 months s/p CVA- can discriminate b/w R + L brain damage
• Healthy Older Adult mean range score= 32-36
• MDC Sub-acute Stroke= 2.22 points
• MDC Chronic Stroke= 3.2 points

4. Fall Risk Reduction: Balance Examination & Intervention
Cara Curran: Sacred Heart University Clinical Rotation Summer 2016
Functional Reach
Population Normative Values
Parkinson’s Disease 33.54 cm
Stroke W/ Arm Sling: 16.8
W/O Arm Sling: 15.2
Subacute: 25.6
Chronic Hemiplegic: 27.1
Chronic Hemiplegic w/ AFO: 28.5
Acute Forward: 31.7
Acute paretic side/non-dominant: 13.8
Acute non-paretic side/dominant: 15.5
Vestibular Disorder 31.7
4 Square Step Test
Dynamic Gait Index
Population Cut Off Scores MDC
Community Dwelling Elderly <19= increased fall risk 2.9 points
Vestibular Disorder <19/24= 2.58x more likely to have Hx
of falls w/in past 6 months
3.2
MS <12= fall risk 4.19-5.54
Parkinson’s Disease <19= faller vs. non-faller 2.9
Stroke <19= fall risk 2.6

5. Fall Risk Reduction: Balance Examination & Intervention
Cara Curran: Sacred Heart University Clinical Rotation Summer 2016
Clock-Drawing
• Attention to task
• Differential diagnosis of
cognitive impairment vs.
neglect
• Score of 7= occurs in 76%
of patients with dementia
• Considerations: increased
age, level of education,
presence of depression,
visual neglect, hemiparesis,
motor dyscoordination
5 Times Sit to Stand
Population Cut Off Scores
Community Dwelling Elderly >12 seconds= fall risk
Vestibular Disorder >13 seconds
Parkinson’s Disease >16 fallers vs. non-fallers
Stroke >12
WHOQOL-BREF
• Assess QOL on the individuals’
perceptions of their position
in life in the context of the
culture and value systems in
which they live in relation to
their goals, expectations,
standards and concerns
Patient Specific Functional Scale
• Patients rate their ability to complete an activity with 0= unable to perform, 10= PLOF
• Patient selects a value that best describes their current level of ability on each activity
• MDC average= +/-3.5 per item or +/-11 for the total
Activities-Specific Balance Confidence Scale
• Self-report measure for patients to rate their balance confidence I performing activities
• Fallers and Non-fallers cut-off: <67% indicates risk for falling (84% of the time)
Mini-Balance Evaluation Systems Test
• Balance assessment tool that aims to target and identify 6 different balance control
systems so that specific rehabilitation approaches can be designed for difference
balance deficits
• MDIC: 4 points+

6. Fall Risk Reduction: Balance Examination & Intervention
Cara Curran: Sacred Heart University Clinical Rotation Summer 2016
Interventions:
The following techniques can be utilized in various postures according to patient CLOF. Postures
can include: prone on elbows, supine, hooklying, sidelying, sitting, quadruped, tall kneeling,
standing, and Single Limb Stance.
Type of
Balance
Purpose Technique
Static
(Rhythmic)
To improve
patient’s control of
stabilization the
segment (static
postural control);
includes an
element of
rotational control
around a segment
Step 1 – cue patient manually and verbally to hold against resistance
(isometric contraction)
Step 2 – switch hands one at a time to opposite side while asking
patient to continue holding
Step 3 - cue patient manually and verbally to hold against resistance in
opposite direction from Step 1 (isometric contraction)
Anticipatory
Postural
Control
Stable when
necessary to shift
weight in
anticipation of
movement from all
positions
Repeated contractions to WB through joint/ quick stretch to muscle
needed to facilitate APC
• Narrow base of support vs. wide
• Transitional movements (STS)
o Tracking objects (laser, another therapist walking
around gym, plane)
Equilibrium
Reactions
Movement
strategies intended
to bring COM back
within BOS
following a
perturbation
• A-P direction: Ankle strategy, Hip strategy, Lowering strategy
• Lateral/diagonal/rotatory directions: Trunk & extremity responses
• Unstable surfaces:
§ Supine & Prone (balls)
§ Sitting (balls, bolsters, balance stools)
§ Standing (bolsters, balance boards)
§ Single Limb Stance
Standing on an incline/decline
Reactionary
Postural
Control
The ability to
maintain upright
when challenged
and regain upright
if lost.
CPAs = Compensatory postural adjustments or contraction (often co-
contraction) of muscles once movement begins
• External perturbations- Therapist, Uneven surface, unexpected
(eyes, closed or distracted)
• Internal perturbations/ loading vs. unloading
• Varying direction, forces, and speeds
Protective
Responses
Movement
strategies to
protect oneself
from a fall when
COM has been
perturbed too far
out of BOS or too
fast for Equilibrium
Reactions to
correct it
• Multi-directional responses using UE or LE
• Trying to push the Pt
§ Stepping strategy and parachute response are an examples
of protective responses
§ Stepping correction: forward, backward, side (R+L)

7. Fall Risk Reduction: Balance Examination & Intervention
Cara Curran: Sacred Heart University Clinical Rotation Summer 2016
Combining
Everything
To make
functional!
• Cognition:
o Hold a conversation while attending to task
o Scanning environment
o TUG w/ dual task (counting backwards from 100)
o Full-system: Driving, negotiating task like cooking with weight
shifts and talking out recipe
• Negotiating obstacles: around, over
• Lateral stepping/ tandem walking
• Ability to change gait speed
• Ambulation with pivots/turns
o Squatting on different surfaces, overhead reaching on toes,
turning while looking up
References:
Anderson, H. D., & Sullivan, J. E. (2016). Outcome Measures for Persons With Acute Stroke: A Survey of Physical
Therapists Practicing in Acute Care and Acute Rehabilitation Settings. Journal of Acute Care Physical
Therapy, 7(2), 76–83. http://doi.org/10.1097/JAT.0000000000000031
Centers for Disease Control and Prevention:
http://www.cdc.gov/Homeandrecreationalsafety/Falls/adultfalls.html/
Center for Healthy Aging: http://www.healthyagingprograms.com/content.asp?sectionid=107
Home Safety Council: http://www.homesafetycouncil.org/SafeSeniors/sen_safeseniors_w001.asp
Howe, T. E. (2012). Exercise for improving balance in older people. Cochrane Database of Systematic Reviews, (5).
Retrieved from http://0-
search.ebscohost.com.enterprise.sacredheart.edu/login.aspx?direct=true&db=chh&AN=CD004963&site=
ehost-live&scope=site
Kendrick, D. (2015). Exercise for reducing fear of falling in older people living in the community. Cochrane
Database of Systematic Reviews, (10). Retrieved from http://0-
search.ebscohost.com.enterprise.sacredheart.edu/login.aspx?direct=true&db=chh&AN=CD009848&site=
ehost-live&scope=site
National Council on Aging: http://www.ncoa.org/
National Safety Council: http://www.nsc.org/safety_home/Resources/Pages/Falls.aspx
Rehab Measures - Clock Drawing Test. (n.d.). Retrieved June 15, 2016, from
http://www.rehabmeasures.org/Lists/RehabMeasures/PrintView.aspx?ID=907
Rehab Measures - Dix–Hallpike Maneuver. (n.d.). Retrieved June 15, 2016, from
http://www.rehabmeasures.org/Lists/RehabMeasures/DispForm.aspx?ID=1010
Rehab Measures - Four Step Square Test. (n.d.). Retrieved June 15, 2016, from
http://www.rehabmeasures.org/Lists/RehabMeasures/PrintView.aspx?ID=900
Rehab Measures - Functional Reach Test / Modified Functional... (n.d.). Retrieved June 15, 2016, from
http://www.rehabmeasures.org/Lists/RehabMeasures/DispForm.aspx?ID=950
The American Physical Therapy Association: http://www.moveforwardpt.com/
The Effect of Interventions on Balance Self-Efficacy in the Stroke Population (n.d.).
The National Blueprint: http://www.agingblueprint.org/tips.cfm
Thank you to June and everyone who has helped teach and guide me during my clinical
rotation! I have learned so much this summer and enjoyed working with you all J