1. Fall Risk Reduction Program Module #6 of 6 Shelley Thomas, MPT, MBA Dara Coburn, M.S., CCC-SLP Shelley Thomas, MPT, MBA Dara Coburn, M.S., CCC-SLP

2. Fall Risk Reduction Program: Review of Modules 1 - 5  In the first module we reviewed the premise of the Fall Risk Reduction Program, including the inclusion criteria for patient selection.  The second module reviewed patient assessment  Identifying patients at risk of falling  Evaluating patients in a dual task condition to simulate “real life” situations  The third module covered how to determine which systems of balance were weakest and develop an exercise program for those systems.  The fourth module looked at IM scores and how to utilize them to establish treatment plans, how to advance exercises based on domains of challenge, and how to gauge progress through reassessment.  In the fifth module, we discussed discharge planning and establishing effective home exercise programs.  In the first module we reviewed the premise of the Fall Risk Reduction Program, including the inclusion criteria for patient selection.  The second module reviewed patient assessment  Identifying patients at risk of falling  Evaluating patients in a dual task condition to simulate “real life” situations  The third module covered how to determine which systems of balance were weakest and develop an exercise program for those systems.  The fourth module looked at IM scores and how to utilize them to establish treatment plans, how to advance exercises based on domains of challenge, and how to gauge progress through reassessment.  In the fifth module, we discussed discharge planning and establishing effective home exercise programs.

3. Module 6 Agenda  Review a case study from start to finish  Patient suitability  Patient evaluation  Determine balance systems impacted  Establish treatment plan  Advancing the exercises  Determining when to discharge  Home exercise planning  Review a case study from start to finish  Patient suitability  Patient evaluation  Determine balance systems impacted  Establish treatment plan  Advancing the exercises  Determining when to discharge  Home exercise planning

4. Case Study Is this patient a suitable candidate for an IM Fall Risk Reduction Protocol  73 year old male with history of three falls in the last two months.  Had L2-5 laminectomy and fusion (July, 2011)  Past medical history significant for CABG x 4 (2010) with documented anoxic event during surgery  Patient and family report cognitive changes after heart surgery.  The patient reports he is still “not quite right”.  73 year old male with history of three falls in the last two months.  Had L2-5 laminectomy and fusion (July, 2011)  Past medical history significant for CABG x 4 (2010) with documented anoxic event during surgery  Patient and family report cognitive changes after heart surgery.  The patient reports he is still “not quite right”.

5. Case Study Is this patient a suitable candidate for an IM Fall Risk Reduction Protocol  Lives alone in 2 story home with 4 steps to enter and 14 steps inside home.  Hires help with housework and cooking.  Receives Meals on Wheels.  Family assists with finances and checks on patient several times per week.  Was participating in regular exercise program until back problems worsened.  Lives alone in 2 story home with 4 steps to enter and 14 steps inside home.  Hires help with housework and cooking.  Receives Meals on Wheels.  Family assists with finances and checks on patient several times per week.  Was participating in regular exercise program until back problems worsened.

6. Case Study Is this patient a suitable candidate for an IM Fall Risk Reduction Protocol  Patient described his falls as “stupid” and “exasperating”.  Fall 1: He caught his toe on a change of surface (moving from carpet to linoleum).  Fall 2: Walking to the mailbox and slipped. Reported he “wasn’t paying enough attention”.  Fall 3: In a parking lot. Patient reports he got distracted by another person and “mis-stepped”.  Referred for physical and speech therapy to address balance and cognitive deficits.  Patient described his falls as “stupid” and “exasperating”.  Fall 1: He caught his toe on a change of surface (moving from carpet to linoleum).  Fall 2: Walking to the mailbox and slipped. Reported he “wasn’t paying enough attention”.  Fall 3: In a parking lot. Patient reports he got distracted by another person and “mis-stepped”.  Referred for physical and speech therapy to address balance and cognitive deficits.

7. Case Study: PT Evaluation  ROM: No significant limitations  Strength: 4/5 throughout upper and lower extremities.  Proprioception: Intact  Vestibular: Unable to walk with horizontal head turns without loss of balance. Also demonstrates LOB with eyes closed activities.  Endurance: Fair – patient reports fatigue after 5-10 reps of exercise  ROM: No significant limitations  Strength: 4/5 throughout upper and lower extremities.  Proprioception: Intact  Vestibular: Unable to walk with horizontal head turns without loss of balance. Also demonstrates LOB with eyes closed activities.  Endurance: Fair – patient reports fatigue after 5-10 reps of exercise

8. Case Study: PT Evaluation TUG = Timed Up and Go TestPatient Score At High Risk for Falling if: TUG alone:11 seconds> 14 seconds TUG Cognitive:16 seconds> 14.5 seconds TUG Manual:18 seconds> 15 seconds (Shumway-Cook, Brauer, & Woollacott, 2000)

9. Case Study: ST Evaluation Subtests from the Ross Information Processing Assessment-Geriatric (RIPA-G), were administered to assess memory and processing skills. * Within Normal Limits Subtest Standard Score Severity Rating Immediate Memory9Moderate Recent Memory13Mild Temporal Orientation12Moderate Spatial Orientation8Moderate Orientation to Environment13Mild Recall of General Info15WNL* Problem Solving and Reasoning13Mild

10. Case Study: ST Evaluation Subtests from the Ross Information Processing Assessment-Geriatric (RIPA-G), were administered to assess memory and processing skills. SubtestStandard ScoreSeverity Rating Organization of Information 8Moderate Auditory Processing and Comprehension 13Mild Problem Solving and Concrete Reasoning 16WNL Naming Common Objects 19WNL Functional Oral Reading 19WNL

11. Case Study “Patient Selection Worksheet” from Module 2

12. LFA

13. Case Study “Designing an Exercise Program” Worksheet from Module 3

15. How to Develop and Advance Treatment Plan Problem Areas Musculoskeletal System Proprioceptive System Vestibular System Oculomotor System Cognition, Communication Strengthening exercises, postural reeducation, balance strategies Challenge cognition/communication, recall, word finding, impulse control, sorting, sequencing, divided and selective attention Uneven surfaces, eyes closed, head turns with gait, spinning, changes of direction

16. Treatment Plan  Received PT and ST, 2x/week x 6 weeks  1 hours sessions per discipline  Performed approximately 30 minutes of IM 2x/week x 6 weeks

18. Advancing the exercises  Cognitive Exercises  STROOP Increase # of stimuli Performed while standing on thin piece of foam  Alphabetizing Increase Alpha difficulty Performed while sitting on physioball  Sorting Increase difficulty level of stimuli Performed while tandem standing  Sequencing Increase difficulty level of stimuli Increased reach distance from base of support  Selective & Divided Attention Increased time on task Increased # of distracting variables  Cognitive Exercises  STROOP Increase # of stimuli Performed while standing on thin piece of foam  Alphabetizing Increase Alpha difficulty Performed while sitting on physioball  Sorting Increase difficulty level of stimuli Performed while tandem standing  Sequencing Increase difficulty level of stimuli Increased reach distance from base of support  Selective & Divided Attention Increased time on task Increased # of distracting variables  Cognitive Exercises  Visual Attention Increase difficulty level of visual stimuli by adding variables Performed with increased base of support reaching modification  Memory Increased amount of information to retain Added multiple auditory distractors during memory task.  Yes/No Questions Performed activity well in all settings. Discontinued after initial trial.  Following Directions Increased # of directions Added in-motion trigger for obstacle course activity.

19. Case Study: Outcomes ExercisePre-LFAPost LFAMs Improvement Both Hands166 ms35 ms131 Right Hand201 ms37 ms164 Left Hand160 ms36 ms124 Both Toes229 ms82 ms147 Right Toe183 ms81 ms102 Left Toe231 ms85 ms146 Both Heels305 ms91 ms214 Right Heel255 ms79 ms176 Left Heel244 ms77 ms167 R Hand / L Toe207 ms89 ms118 L Hand / R Toe234 ms90 ms144 Balance R FootUnable101 ms* Balance L FootUnable121 ms* Both Hands-GDE252 ms32 ms220

20. Case Study: Outcomes Test Intake Patient Score At High Risk for Falling if: Discharge Patient Score TUG alone:11 seconds> 14 seconds9 seconds TUG Cognitive: 16 seconds> 14.5 seconds13 seconds TUG Manual:18 seconds> 15 seconds13 seconds (Shumway-Cook, Brauer, & Woollacott, 2000)

21. Case Study: ST Outcomes Subtests from the Ross Information Processing Assessment-Geriatric (RIPA-G), were administered to assess memory and processing skills. * Within Normal Limits SubtestIntake Severity Rating Discharge Severity Rating Immediate MemoryModerateMild Recent MemoryMildWNL Temporal OrientationModerateWNL Spatial OrientationModerateMild Orientation to EnvironmentMildWNL Recall of General InfoWNL*WNL Problem Solving and Reasoning MildWNL

22. Case Study: ST Outcomes Subtests from the Ross Information Processing Assessment-Geriatric (RIPA-G), were administered to assess memory and processing skills. Subtest Intake Severity Rating Discharge Severity Rating Organization of InformationModerateMild Auditory Processing and Comprehension MildWNL Problem Solving and Concrete Reasoning WNL Naming Common ObjectsWNL Functional Oral ReadingWNL

23. Determining when to Discharge

24. Home Exercise Planning

25. Post-test  Complete post-test for Module 6

26. Materials Page  This video  PowerPoint  Case Study Worksheets  www.interactivemetronome.com/ind ex.php/fall-risk-coaching www.interactivemetronome.com/ind ex.php/fall-risk-coaching  This video  PowerPoint  Case Study Worksheets  www.interactivemetronome.com/ind ex.php/fall-risk-coaching www.interactivemetronome.com/ind ex.php/fall-risk-coaching

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