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THERAPEUTIC TECHNIQUES

FOR MANAGING THE HOME

HEALTH PATIENT

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information contained in this presentation.

COURSE OBJECTIVES

The clinician will recognize the patient’s risk factors and be able to compile

a problem list which correlates with deficits identified by standardized tests

The clinician will be able to utilize standardized tests to develop a multi-system treatment plan to maximize patient function

The clinician will be able to identify functional limitations and focus their

treatment approach on specific deficits contributing to the patient’s

disability

The clinician will be able to document findings in a concise manner by correlating objective findings with functional deficits and functional goals

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FRAILTY AND FALL RISK IN THE ELDERLY

FRAILTY RISK FACTORS

Unintentional Weight Loss of 10 lbs or more in the past year

Report of Fatigue or Exhaustion

Weakness in LEs and Decreased Grip Strength

Decreased Gait Speed and Step Length

Low Physical Activity

Elderly adults with 1-2 of the above risk factors are considered Prefrail or Intermediate Frail. Elderly adults with 3 or more of these risk factors are considered clinically frail. (Kett M, 2011)

FRAILTY AND FALL RISK FACTORS

FALL RISK FACTORS

Taking 4 or more medications

Use of an assistive device

History of Falls within the past year

History of Dizziness

Gait or Balance Disorder

Low Vision

INTRINSIC FALL RISK FACTORS

Age 65 or older 2 times more likely to fall; >80 3 times more likely to fall

1 out of 3 adults age 65 or older will fall each year

20-30% of falls will result in serious injury

25% who suffer fractures will die within the first year following injury

Falls are the number one cause of TBI (Traumatic Brain Injury) in older adults

with 46% being fatal

Falling, even without injury, increases one’s fear of falling and leads to reduced mobility and functional decline.

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EXTRINSIC FALL RISK FACTORS

Home Environment- throw rugs, slippery floors, clutter, poor lighting,

unstable furniture or unsafe chairs, no grab bars, nonslip surfaces in

tub/shower, low toilet seats

Outside Environment- uneven sidewalks, steps, poor access to home, poor

lighting, snow, wet grass or leaves

Activities- sit to stand, getting up to go to the bathroom at night, improper

footwear, poorly maintained assistive device

1/2 - 1/3 falls sustained by community dwellers are due to extrinsic factors

(Kett M, 2011)

BEST PREDICTORS OF FALL RISK

BERG BALANCE SCALE

Single best predictor of falls

Correlates with TUG, TINETTI, DGI and FUNCTIONAL REACH

SELF REPORT OF FALL PERCEPTION OR FEAR OF FALLING

IDENTIFYING FALL RISK

Falls Efficacy Scale

Motion Sensitivity Quotient

Functional Assessments

OPTIMAL Functional Limitation Scale

Patient Specific Participation Scale

Barthal Index

Functional Independence Measure

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Falls Efficacy Scale

14 item patient questionnaire that identifies activities of daily living which

the patient does not feel comfortable performing due to a fear of falling

This can be used to design treatment intervention to improve patient confidence and to reduce motion sensitivity secondary to vestibular

hypofunction.

Objective measurement which can be used for establishing goals and

reassessing the patient’s progress

MOTION SENSITIVITY QUOTIENT

16 item test that assesses specific head and body movements associated

with dizziness

The patient rates the intensity of the dizziness on a 1-5 scale and the duration of the dizziness symptoms is recorded.

Beneficial when dealing with a BPPV because it assists in pinpointing the

baseline symptoms and tracking resolution of symptoms objectively.

Functional Assessment

OPTIMAL FUNCTIONAL LIMITATION SCALE- 22 item self assessment of function, scored according to difficulty and confidence using a 5 point scale. Computes into a functional limitation score for G codes.

PATIENT SPECIFIC PARTICIPATION SCORE- self assessment in which the patient identifies 5 areas of functional limitation and rates their difficulty; can be translated into G codes.

BARTHAL INDEX- 10 item functional score, assessing the patient’s ability to perform ADLS; the lower the score the higher the disability.

FUNCTIONAL INDEPENDENCE MEASURE- 18 item assessment which measures functional limitation and cognition to determine disability level and the amount of assistance needed for ADLS.

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STANDARDIZED TESTS AND

HOW THEY CORRELATE WITH

FUNCTION

VESTIBULAR-OCULAR SYSTEMS

CENTRAL VESTIBULAR TESTS

Smooth Pursuit

Saccades

PERIPHERAL VESTIBULAR TESTS

Vestibular-Ocular Reflex

Head Thrust

Dynamic Visual Acuity

SMOOTH PURSUIT

Tests the ability to follow a moving target

Performed by having the patient follow a target throughout all

planes including on a diagonal

Important for the elderly while watching TV, reading or engaging in

social activities

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SACCADES

Tests the ability of the eye to change direction rapidly to maintain its

focus on a moving target

Performed by having the patient alternately look from one object to another upon verbal cueing

Important for the elderly population for activities such as watching

their grandson participate in a sports activity like basketball without becoming dizzy or losing their balance.

VESTIBULAR OCULAR REFLEX

Tests the eyes ability to maintain focus on an object while the head is in

motion

The patient’s head is placed in 30* of flexion and he patient is instructed to maintain their gaze on the therapists nose while the therapist rotates the

head side to side.

The test is positive if the patient develops sacaddic eye movement or

complains of dizziness or nausea

HEAD THRUST

Tests for peripheral vestibular dysfunction indicative of BPPV

The patient’s head is placed in 30* of flexion, then taken to end range of

rotation and swiftly rotated to the opposite side

The test is positive if the patient develops saccadic eye movement or

complains of dizziness or nausea

The test is positive for the side opposite the rotation

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VIDEO

SMOOTH PURSUIT

VOR

HEAD THRUST

Link to “Therapeutic Techniques for Managing the Home Health Patient”

videos.

Home Health Video Link

(url: http://vimeopro.com/user12715381/therapeutic-techniques-for-managing-the-home-health-

patient/video/69992879)

DYNAMIC VISUAL ACUITY

Tests the ability to stabilize one’s gaze while the head is moving

Performed by having the patient read an eye chart with the head

still and then while you passively move the head; a difference in visual acuity of greater than 2 lines is a positive test for vestibular

hypofunction.

Important in the elderly population for scanning shelves in a grocery store

VIDEO

DVA TESTING*

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BENIGN PAROXYSMAL POSITIONAL VERTIGO

Under diagnosed

Cannot be diagnosed correctly without testing

Often has latent affects such as balance problems, light-headedness, a feeling of floating, avoidance behaviors and vestibular hypofunction

Nystagmus is a BONUS!!!

CONTRAINDICATIONS TO POSITIONAL TESTING

Cervical Instability – drop attacks, dysphasia or dysarthria

Severe RA or Chiari Malformation

Radiculopathy of All 4 Extremities- indicates cord compression

Post-op Cervical Surgery

POSITIONAL VESTIBULAR TESTS

Sharp Purser-tests ligament stability at C1C2 vertebra; must be

completed before positional tests.

Dix Halpike- tests presence of otoconia in the anterior and posterior

semi-circular canals.

Roll Test- tests presence of otoconia in the horizontal canal.

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PRECAUTIONS FOR PERIPHERAL VESTIBULAR TESTING

Severe OA

Postural Changes (Kyphosis)

Recent Trauma/Whiplash

Modified Testing: a recliner can be used to test individuals who are

severely kyphotic or lack sufficient cervical ROM to test in the traditional test position. The recliner can be tilted backwards and

the testing performed; this requires 2 clinicians.

SHARP PURSER

To perform, the clinician places one hand with fingertips over the

axis and the other hand on the forehead, then asks the patient to

push forward into the hand on the forehead as if nodding. No movement should be felt in the cervical area.

DIX HALPIKE

Tests for otoconia in the anterior or posterior semi-circular canals

Patient placed in long sit

Clinician rotates head 45* to one side and places head in 30* extension

Clinician assists patient to supine position

Positive if nystagmus present or if patient c/o dizziness, vertigo or nausea/vomiting.

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VIDEO

Dix Halpike in Clinic

Dix Halpike in Recliner*

ROLL TEST

Tests for otoconia in the horizontal semi-circular canal

Patient placed in long sit

Clinician rotates head 45* to one side and places head in 30* of flexion

Clinician assists patient to supine position

Nystagmus more probable; positive if patient c/o dizziness, vertigo or nausea/vomiting.

MUSCULOSKELETAL SYSTEM

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CERVICAL POSTURE

Observe the patient for forward head posturing and for rotation to

the left or right.

Important for proper gaze stabilization and the patient’s ability to

scan their environment for obstacles

Resistance to head movement to one side or permanent posturing of the head in rotation to a specific side may be indicative of an

unresolved BPPV

OBJECTIVE MEASURES OF HEAD

POSTURE

Tragus to Wall

Tragus to Wall >10cm indicative of translation of C7 through T8 (Viitanen JV et al,

1998)

Have the patient stand erect with heels and buttocks against the wall

Measure the distance from the wall to the tragus of each ear

Average the distance of both sides

0 cm occiput to wall indicative of good cervical alignment

>10cm indicative of translation of C7 through T8 (Viitanen JV et al, 1998) and

indicative of forward head posture which should be addressed in therapy

If the distance on the right and left are different this indicates cervical rotation

OBJECTIVE MEASURES OF CERVICAL

ROM

Occiput to Wall

Have the patient stand straight with heels and buttocks against the

wall

Have subject try to place the back of the head against the wall

Measure the distance from the wall to the occipital prominence

>7cm indicative of possibility of thoracic compression fracture (Siminoski et al, 2003) and should be addressed in therapy

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THORACIC POSTURE

Thoracic kyphosis results in backward lean, decreased lumbar lordosis,

shortened anterior trunk musculature, hyperextension of the knees, ankle

eversion and pronation of the feet

This results in increased difficulty reaching, increased time to climb stairs

and increased difficulty performing housework. (Ryan SD, Fried LP, The

Impact of Kyphosis on Daily Functioning, 1997)

Thoracic kyphosis secondary to compression fractures can be painful and

can limit tolerance for standing to perform ADLS/IADLS

Thoracic kyphosis can significantly impair rib mobility and lung volume

RIB MOBILITY

Decreased rib mobility reduces lateral basal lung expansion with respiration

Lateral basal expansion should be between 4-6 cm

To measure lateral basal lung expansion place a tape measure around the ribcage with the tape overlapping the end

Have the patient take a deep breath in and allow the tape measure to

move with the ribs

Measure the difference between the rib circumference at maximum inspiration and maximum expiration

Improving rib mobility is critical for patients with CHF and COPD

LUMBAR POSTURE

Rib/Pelvis Distance

Indicative of possible osteoporosis and possible lumbar vertebral compression fracture

The distance from the inferior margin of the ribs to the iliac crest should be 4 fingers.

A distance of 2 fingers or less is indicative of lumbar kyphosis and possible compression fracture and should be further investigation

Lumbar kyphosis or posterior pelvic tilt of the pelvis disrupts balance and increases difficulty performing sit to stand because the patient’s center of gravity moves posterior to the hip joint making it more difficult to push to stand.

Anterior/Posterior pelvic tilt and superior/inferior lateral tilt of the pelvis is necessary for ease of transfers and gait

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Measuring Spinal ROM Using a Tape

Measure

Cervical Spine

Initial measure – final measure = ROM amount

Flexion/Extension-measure from the tip of the chin to the sternal notch

Lateral Flexion- measure from the mastoid process to the lateral tip of the

acromion process; avoid rotation and shoulder shrug

Rotation- measure from the tip of the chin to the lateral tip of the acromion;

do not allow flexion/extension or lateral flexion

(Reese NB, Bandy WD, Joint Range of Motion and Muscle Length Tests, 2002)

Measuring Spinal ROM Using

a Tape Measure

Thoracic Spine

Initial measure – final measure = ROM amount

Extension- measure in standing; have patient cross their arms and place their hands on the opposite shoulders; measure from the ipsilateral

acromion process to the greater trochanter of the contralateral femur

Thoracolumbar Lateral Flexion- have the patient stand with feet shoulder

distance apart with palms parallel to and against the thighs, then slide

hand down thigh and measure the distance from the tip of the middle finger to the floor

SHOULDER ELEVATION

Scaption or scapular plane elevation in the midrange between straight plane shoulder flexion and abduction is the most functional range for the elderly patient.

At least 100*-120* of shoulder elevation is necessary to reach overhead to perform ADLS such as washing hair or for reaching into an overhead cupboard for a glass.

Limitation in scaption affects shoulder internal rotation and external rotation and this can lead to additional loss of ability to perform ADLS/IADLS.

Weakness of the scapular stabilizers (middle/lower trap, rhomboids, serratus anterior and posterior) can result in a decrease in shoulder elevation.

If the patient cannot be placed prone to test these muscles then assess shoulder elevation sitting or standing and in supine. If the patient has greater shoulder elevation in supine than sitting or standing then there is weakness of the scapular stabilizers and this should be addressed in therapy.

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SCAPULAR WINGING

Poor scapular stabilization can lead to pain in the shoulders and ultimately to impingement syndrome and /or tendon damage, further limiting upper extremity function.

Observe the patient’s scapula with arms at their side and then with shoulder elevation to 90*

Winging with shoulder elevation is indicative of poor scapular stabilization and should be addressed in therapy

Scapular winging can be objectively measured and improvement tracked by measuring the distance from the inferior angle of the scapular to the thoracic spinous process at the same level. (This is not a validated measurement method but experience has shown that this distance decreases as strength of the scapular stabilizers improves and winging decrease).

Pelvic Girdle Alignment

The patient must be able to anteriorly and posteriorly tilt the pelvis to keep their center of gravity positioned between the hips.

An increase in either anterior or posterior positioning of the pelvis can disrupt both sitting and standing balance and prevent the patient from making necessary adjustments when ambulating on inclines, steps or uneven surfaces such as grass, gravel or snow.

The patient must also be able to elongate and shorten the trunk with weight shift for proper balance reactions in both sitting and standing.

The patient must be able to anteriorly tilt the pelvis for ease of transition from sit <> stand.

Excessive anterior pelvic tilt or excessive posterior pelvic tilt can be a source of pain for the elderly and this can interfere with their function.

Hip Flexion/Extension

At least 10* of hip extension is necessary for dynamic stand balance

Loss of hip extension interferes with step reactions for dynamic stand

balance

At least 100* of hip flexion is necessary to allow the shoulders to move

anterior to the hips for sit to stand.

Hip flexor tightness disrupts pelvic girdle alignment and can interfere with

balance reactions in stand.

As we age hip range of motion from end range of flexion to end range of

extension decreases and results in instability during gait.

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Hip Flexion/Extension and Gait

Heel contact to foot flat phase of gait requires 30* of hip flexion

Foot Flat to Heel Off requires progression from 30 * of hip flexion to ---10* of hip extension

Heel Off to Toe Off requires progression form -10* of hip extension to 0* of hip flexion

Swing phase of gait requires progression from 0* of hip flexion to 30 * of hip flexion

The hip extensors are most active during heel contact to foot flat, and in the late swing phase of gait

Any loss of hip range of motion is going to result in a gait deviation that can effect gait speed, step and stride length and stability in stance phase of gait.

Assessing Hip Extension in the Elderly

Have the patient lie supine and check for SLR to 45*.

Cup both hands under the patient’s heel of the leg being tested

As you raise the leg to approximately 36 inches, ask the patient to push down into your hand keeping the hip locked

5/5- maintains hip at neutral

4/5- hip breaks but catches at any point in the range and the pelvis rises off

table

3/5- good resistance is felt but the pelvis does not rise off the bed

2/5- minimal resistance is felt throughout the range

Hip Abduction/Adduction

The gluteus meidus, gluteus minimus and tensor fascia lata are critical to

stability during stance and swing phase of gait

During swing phase of gait these muscles are actively abduct on the stance side and are responsible for maintaining the pelvic girdle in the frontal

plane

During stance phase of gait these muscles control adduction and prevent

the pelvis from dropping

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Trendelenburg Test

Assesses the strength of the gluteus medius in stance

Have the patient perform one leg stance for 10 seconds on each leg

Observe the level of the pelvis, which should remain at the same height on both sides

If the pelvis drops lower on the unsupported side than on the stance leg side

then the test is positive

Indicates instability at the hip on the stance side

Results in a lurch to that side and can cause back pain during gait due to

shortening of the trunk with weight shift rather than elongation which is what

should occur

Knee Flexion and Extension

>90* of knee flexion is needed for sit to stand in order facilitate residual

spinal level reflexes to assist with this maneuver.

At least 90*-100* of knee flexion is desirable for stair climbing

0* of knee extension is needed for stability in stance phase of gait

Good eccentric control of the quads and gluteals is essential for grading

stand to sit and for descending stairs

Good eccentric control of the lumbar paraspinals, hamstrings and gastocsis needed for forward bend to perform functional reach

19% of dynamic balance is attributable to knee strength

Knee Flexion/Extension and Gait

During heel contact to foot flat the knee progresses from 5* to 15* of knee

flexion.

During foot flat to heel off, the knee progresses from 15*of flexion to -4 * extension.

Heel off to toe off requires 40* of knee flexion.

Swing phase of gait requires progression from 65* of flexion to 0* of

extension.

The quadriceps is most active during foot flat to toe off and then again

during the swing phase of gait.

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Ankle and Foot

10*-15* of ankle dorsiflexion is necessary for adequate ankle strategies on uneven or compliant surfaces, for limits of stability to reach out of one’s base of support and for toe clearance during gait

Limits of stability for the ankle in standing 8* forward and 4.5* backward

Mobility of the toes, transverse arch of the foot and the metatarsal and tarsal joints is critical to stability in stance phase of gait

The foot must be mobile to accommodate to varying surfaces (grass, thick carpet, gravel) and to safely transition from one surface type to another (doorways, tile to carpet, cement to grass).

The patient must be able to get their heels behind their knees in order to push through the heel for sit to stand.

Ankle strength is more correlated to stooping, crouching, and kneeling than proximal leg strength.

Ankle Motion and Gait

Heel contact to foot flat requires 0*-15 of plantarflexion.

Foot flat to heel off phase of gait requires progression from 15* of plantarflexion to 25* of dorsiflexion.

Heel off to toe off requires progression from 25*of dorsiflexion to 30* of plantarflexion.

Swing phase requires 10* of dorsiflexion for foot clearance and heelstrike.

The dorsiflexors are most active during heel contact to foot flat and during swing phase of gait.

The plantarflexors are most active during foot flat to heel off phase and the toe flexors are active from heel off to toe off.

The dorsiflexors and plantarflexors become more active during gait on inclines and steps because greater foot clearance and eccentric control is necessary to maintain stability on these surfaces. Ankle inversion and eversion are also critical for negotiating uneven, inclined or compliant surfaces safely.

Ankle and Hip Strategies for Postural

ControlAnkle Strategy

Head and hips move in the same direction

Contractions move distal to proximal

Utilized for slow/small perturbations

Hip Strategy

Head and hips move in the opposite direction

Contractions occur proximal to distal

Utilized for large/fast perturbations

More commonly used by the elderly

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Muscle Strength and Function

Abdominals / Back Extensors – weakness interferes with performance of

transitional movements from one posture to another and contributes to back

pain during gait.

Scapular Stabilizers-weakness interferes with reaching and results in shoulder

pain due to impingement

Pelvic Girdle Stabilizers- weakness results gait disturbances and back pain with

ambulation

Lower Extremities- weakness results in poor foot clearance during gait, difficulty performing steps, difficulty negotiating obstacles and difficulty performing

transfers.

SOMATOSENSORY SYSTEM

PAIN

Pain interferes with function and is a major limiting factor in mobility.

Pain reduction utilizing modalities such as infrared light, ultrasound, TENS and heat/cold can significantly improve outcomes in the elderly population.

Addressing pain issues is the responsibility of every therapist prior to discharging a patient, especially if the reason for discharge is pain limiting their ability to participate.

Pain Assessment

VAS Pain Scale

1-10 scale, utilized to objectively measure pain level at each

therapy visit

Accuracy is questionable in the elderly because many don’t

understand the scale

FACES Scale

Correlates faces with VAS scale

Easier for the elderly to understand

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SOMATOSENSORY SYSTEM

SENSATION

Loss of protective sensation in the feet can significantly increase fall risk.

Patients with LOPS will furniture walk or utilize an assistive device to increase their sensory feedback through their upper body to compensate

for the lack of feedback in the lower extremities.

Infrared light therapy is a valuable tool for improving circulation in the

lower leg and thereby, improving sensation.

SENSORY ASSESSMENT

Semmes Weinstein Monofilament Test: utilizes a monofilament to test

sensation over the sole of the foot and the palmar surface of the hand.

Can utilize 5 point or 10 point scale for each foot.

5.07/10g monofilament is recommended to identify peripheral neuropathy

Charts are available for tracking the patient’s progress and the test provides

an objective measure of change if a modality such as infrared is being

utilized.

BALANCE

Modified Clinical Test for Sensory Integration and Balance

4 step test that measures the degree to which each sensory system contributes to the

patient’s equilibrium

Assists the clinician in determining which system the patient relies on and which systems

must be facilitated

Provides evidence for gait instability on compliant surfaces and in low light

Can be used as a treatment intervention in preparation for gait training on uneven or compliant surfaces and to improve gait in low light situations such as getting up during the

night to go to the bathroom or walking down a dark hallway to get to a bedroom.

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BALANCE

Single Limb Stance Tests unilateral stance for up to 30 sec

The subject stands on their dominant foot (preferably barefoot) with their arms crossed and eyes open; timing begins as soon as one foot leaves the floor and stops as soon as the suspended foot hits the floor.

A score of 5 seconds or less is indicative of a high risk for injurious falls

At least 10 seconds is necessary to perform a transfer into a tub

Important for stair climbing, curbs and negotiating obstacles such as small pets or a grandchild’s toy

Good treatment intervention when coupled with sensory integration activities

BALANCE

Functional Reach

Tests ability to reach out of base of support

The subject stands with feet a comfortable distance apart, raises his arm to 90*, makes a fist and reaches as far forward as possible without losing their balance or taking a step. A

ruler or yardstick is used to measure the distance reached.

6-10 inches-2 x more likely to fall; <6 inches-4 x more likely to fall; unable to reach- 8 x

more likely to fall

Provides evidence for fall risk with functional activities such as reaching into overhead

cabinets or leaning forward to brush one’s teeth

If the patient has back pain this test can be a good objective measure of pain limiting

function and is another measure to reassess along with pain for objective improvement.

BALANCE

Berg Balance Test

Measures balance while performing 14 functional tasks

Utilizes a 5 point scale with a maximum score of 56

0-20 high fall risk; 21-40 moderate fall risk: 41-56 low fall risk

Identifies the tasks which pose the greatest fall risk for the patient

Portions of the test can be used for establishing goals for treatment and for

treatment intervention to improve functional tasks.

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Gait Speed is the 6th Vital Sign

Gait Speed has become the “single best predictor of functional decline and

disability” (Gillet al1195, Guranlnik et al 2000, Studenski et al 2003)

Multiple studies have proven gait speed to be a reliable predictor of:

Functional Decline Hospitalization

Mortality Potential for Rehabilitation

Discharge Location Falls and Fear of Falling

Determining Gait Speed

4 meters is considered the most appropriate for homebound patients

Allow 2 meters for acceleration and 2 meters for deceleration

The subject begins walking at their normal speed; timing begins when they cross the 2 meter mark and ends when they hit the 6 meter mark. (Total

distance 8 meters)

Allow the subject one trial run and then allow 2 trials for normal speed and 2

trials for fast speed; record the best time.

Divide the gait distance by the gait time (m/sec)

An improvement of .05m/sec is considered significant

Gait speed correlates with the TUG and the Berg Balance Test

Gait Speed and Community Ambulation

1.2 m/sec-1.3 m/sec is the normal walking speed for adults

1.2 m/sec is necessary to cross the street safely

<1.0 m/sec is indicative of a high risk for health related problems

0.5 m/sec is sufficient for community ambulation

0.4- 0.8 m/sec indicates high risk for functional decline within one

year

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GAIT

Tinetti Test for Balance and Gait

The balance portion scores the patient on their ability to maintain unsupported sit,

perform sit to stand, sternal nudge, standing with eyes closed and turning and stand to sit

The gait section scores the patient on gait initiation, step length, symmetry and

continuity, trunk deviation and heel sdistance.

25-28-low fall risk; 19-24-moderate fall risk; <19- high fall risk

Portions of the test can be used to establish goals for treatment and to identify

specific activities to work on in the therapy sessions

GAIT

TUG- Timed Up and Go

Tests sit to/from stand, turns and gait speed over 10ft or 3M

<10 sec indicates the patient is Freely Mobile

11-20 sec Mostly Independent

>20 sec Limited Mobility

>30 sec Dependent

Adult community dwellers should be able to complete the test in 12 sec or less.

Fall risk if score is >13.5 sec

GAIT

Dynamic Gait Index

Measures gait quality with head movements and changing speeds

Full Test-8 items; highest score 24; <20 indicates a fall risk

Modified Test- 4 items; highest score 12; <10 indicates fall risk

Can be utilized as a treatment intervention for improving gaze

stabilization during gait.

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SUMMARY OF

FUNCTIONAL PARAMETERS

HIGH LEVEL OF FUNCTION

Functional Reach: >11 inches, not likely to fall

Berg Balance Test: 41-56/56, low fall risk

Gait Speed: >1.5m/sec, community ambulatory

Tinetti: 24-28/28 low fall risk

TUG: <10 sec, community ambulatory

DGI: 24/24 complete test; 12/12 modified test, community ambulator

INTERMEDIATE LEVEL OF FUNCTION

Functional Reach: 6-10 inches, 2 times more likely to fall

Single Limb Stance: 5-10 sec, moderate fall risk

Berg Balance Test: 21-40, moderate fall risk

Gait Speed: .9 – 1.9 m/sec, well functioning

Tinetti: 20-23, moderate fall risk

TUG: 9-20 sec, moderate fall risk

DGI: 19-23/24 complete test or 9-11/12 on modified test, moderate fall risk

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LOW LEVEL OF FUNCTION

Functional Reach: < 6 inches, 4 times more likely to fall

Single Limb Stance: <4 sec, high fall risk

Berg Balance Scale: 0-20/56, high fall risk with functional activities

Gait Speed: .5-.8 m/sec; very limited mobility and may require an assistive

device

Tinetti: <19/28, high fall risk

TUG: <20 sec, limited mobility and may require an assistive device

DGI: 18 or less on complete test or <9 on the modified test indicates high

probability of a fall

DEVELOPING A TREATMENT

PLAN THAT ADDRESSES

FUNCTIONAL LIMITATIONS

VESTIBULAR-OCULAR DEFICITS

INTERVENTIONS

Canalith Repositioning

Habituation Activities

Gaze Stabilization Exercises

Compensatory Activities

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CANALITH REPOSITIONING

EPLEY MANEUVER: corrects an anterior/posterior canalithiasis and can be performed as a

continuation of the Dix Halpike.

SERMONT A OR P LIBERATORY MANEUVER: corrects an anterior or posterior cupulolithiasis.

APPIANI MANEUVER: corrects a horizontal canalithiasis.

HORIZONTAL LIBERATORY MANEUVER: corrects a horizontal cupulolithiasis.

Provide post treatment instructions to sleep with head elevated and avoid excessive

activity for 24 hours.

Follow-up canalith repositioning with instruction in Brandt Darof exercises or otolith

stimulation activities to recalibrate the vestibular system.

VIDE0

EPLEY CORRECTION*

HABITUATION ACTIVITIES

Utilize with patients who report dizziness or disequilibrium with certain

activities or who report motion sensitivity on the MFES or MSQ

Questionnaires

Activities include rolling, long sit to supine, sidelying to sit, sit to stand, and

bending over to reach for objects

These activities can be performed with the head in different positions or

through varying ranges

Document number of reps in a given timeframe, any LOB, or error signals such as dizziness

It may take 1-2 months to resolve the residual motion sensitivity so don’t

discharge too soon!

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VIDEO

SACCADES

SIDELYING TO SIT HABITUATION

GAZE STABILIZATION EXERCISES

Utilize when the patient tests positive for vestibular hypofunction (DVA > 2

line difference) or when VOR test is positive.

Have the patient perform smooth pursuit, saccades or VOR exercises in sitting, standing with NBOS, WBOS and on various surfaces such as

compliant foam, wedge or in step stand position.

Have the patient perform head turns and head nods while in sitting,

standing with NBOS, WBOS, and on various surfaces both in sitting and

standing.

Maintain objective documentation by counting reps completed in 30 sec or

up to 2 min intervals; record # of error signals or instances of LOB while

performing the activity

VIDEO

VOR HEAD TURNS

VOR HEAD NODS

SEATED ON DISC VOR AND BALANCE*

SEATED ON DISC 2

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COMPENSATORY ACTIVITIES

Utilize with patients who have central vestibular deficits

Choose activities which the patient identifies as causing a fear of falling or

activities which have resulted in a fall

Have the patient perform functional activities, such as sit to stand, turning or

sit to supine while focusing gaze their gaze on a fixed object

Have the patient perform gait activities, such as focusing on a picture at

shoulder level as they walk across the room, turning their head and body as

needed to maintain the focus.

DOCUMENTING GOALS AND OBJECTIVE

MEASURES

GOALS

1) The patient will demonstrate improved gaze stabilization as evidenced by

a 2 line or less difference on the DVA, so he can scan shelves in the grocery store without disequilibrium.

2) Resolve dizziness as evidenced by no dizziness reported with sit to stand x

1 week so the patient can participate in his church services.

3) Resolve BPPV, as evidenced by a negative Dix-Halpike, so the patient can

resume driving without dizziness.

4) The patient will demonstrate improved tolerance for saccades, as

evidenced by 20 reps in 30 sec so she can watch her grandson play

basketball without feeling nauseous or dizzy.

DOCUMENTING GOALS AND OBJECTIVE

MEASURES

OBJECTIVE MEASURES

1) The patient completed 10 reps of saccades in 30 sec without an error

signal.

2) The patient completed 20 reps of head nods in 30 sec while standing on

compliant foam to improve sensory integration of the visual, vestibular

and somatosensory systems.

3) The patient completed 5 sets of rolling to the right with 10 sec hold in each

position following error signal; Rep 1- 2 sec onset of dizziness lasting 13 sec; Rep 2- 2 sec onset of dizziness lasting 10 sec; Rep 3- 4sec onset of

dizziness, lasting 8 sec, etc.

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Postural Deviations/Musculoskeletal Deficits

Interventions

Chin tucks, upper trap and scalene stretches, pectoral stretches, seated thoracic and

lumbar stretches, hip flexor and hamstring stretches, gastroc stretches and rotation of the trunk.

Mobilization of the scapula, glenohumeral joint, rib cage, tarsal joints, interphalangeal

joints of the toes, the fibula and the tarsal joints. Kinesio-taping can be beneficial in

facilitating muscle function and aligning posture but must be used with caution in the

elderly population.

Reverse “C”, seated crunches, seated oblique crunches, overhead reach, overhead

reach with hip extension on the opposite side, step-up on foam with hip abduction of the

opposite leg, seated weight shift side to side while performing overhead or forward reach

on the same side

VIDEO

ANTERIOR/POSTERIOR TILT*

SIDE TO SIDE WEIGHT SHIFT

SEATED CRUNCHES*

THERABAND EXERCISES*

ECCENTRIC HIP CONTROL*

DOCUMENTING GOALS AND OBJECTIVE

MEASURESGOALS

1) The patient will demonstrate improved anterior pelvic tilt so she can maintain her

center of gravity between the hips upon sit to stand and not fall backwards.

2) The patient will have 10* of ankle dorsiflexion so he can reach out of his base of

support at least 11 inches, in order to reach into her medicine cabinet.

3) The patient will demonstrate eccentric quad control so he can descend 5 steps using

one handrail (I) to get out of his home and to his car.

4) Reduce back pain to <2/10 utilizing ultrasound to the lumbar paraspinals so the

patient can stand at least 10 minutes to wash her dishes.

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DOCUMENTING GOALS AND OBJECTIVE

MEASURES

OBJECTIVE MEASURES

1) PT performed passive stretch to the bilateral gastrocs for 20-30 sec hold x

5 reps each, to improve ankle limits of stability for functional reach.

2) PT provided tactile cues for anterior tilt of the pelvis during sit to stand to

keep the patient’s center of gravity between her hips and facilitate push

through her heels to come to stand.

3) PT facilitated weight shift with tactile cues to improve trunk elongation on

stance leg during standing hip abduction exercises.

4) PT educated the patient in proper body position for sit to stand- shoulders

in front of hips, heels behind knees and anterior tilt of the pelvis.

Pain and Sensory Deficits

Interventions

Modalities of ice massage, therapeutic massage, myofascial release and

joint mobilization can be utilized in the home without the need of equipment.

Infrared light therapy, ultrasound, electrical stimulation are other effective

modalities to consider for use in the home but are expensive and therefore

not usually available.

TENS can be a very effective modality for pain management, is easily obtained through a vendor and can be delivered directly to the patient.

Infrared light therapy and sensory stimulation are beneficial for loss of

protective sensation.

VIDEO

INFRARED SENSORY STIMULATION

STEP UP ON FOAM*

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Pain and Sensory Deficits

Goals

1) The patient will demonstrate a decrease in back pain from 8/10 to 2/10

while standing at least 10 minutes to wash dishes.

2) The patient will tolerate walking at least 500ft without onset of knee pain so

he can ambulate from his car into his doctors office for appointments.

3) The patient will demonstrate improved somatosensory feedback as

evidenced by improvement in his Semmes Weinstein score from 3/10 to 7

/10, so he can negotiate the gravel driveway which leads to his car.

Balance and Gait Deficits

INTERVENTIONS

1) Focus on those activities the patient has the most difficulty performing.

2) Breakdown tasks into segments and work on pieces of a motion first, then try the entire activity.

3) Utilize sensory integration principles, making sure to stimulate multiple systems at one

time.

4) Always end the session with functional training, utilizing the activities you worked on in the session.

Balance and Gait

Interventions

1) Anterior /posterior and side to side weight shift in sitting, standing and then

on complaint surface or inclined surface.

2) Single limb or step stand activities, stepping on or over objects, standing

with one foot on compliant surface and one on firm surface while

performing arm movement or head movements.

3) Obstacle course, figure 8, walking in a circle, marching in place, four

square stepping, toe tapping.

4) Side stepping, walking backwards, ambulating in darkened room, or

outdoors with head turns or nods.

5) Practice step reactions to the side, back and forward; grapevine.

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VIDEO

SENSORY TRAINING ON FOAM WITH HIP ABDUCTION*

SENSORY INTEGRATION AND REACHING*

ROCKING FORWARD AND BACKWARD*

TOE TAP, SINGLE LIMB STAND, VOR

BALANCE AND GAIT

GOALS

1) The patient will demonstrate improved single limb stance for 10 sec so he

can safely get into and out of his tub.

2) The patient will demonstrate improved balance as evidenced by a

MCTSIB score of 4/4 so he can ambulate to his mailbox on his gravel

driveway.

3) The patient will have a reduced fall risk as evidenced by a Tinetti score of

26/28 so she can negotiate obstacle in her path, such as her small dog and her grand-daughter’s toys.

SENSORY INTEGRATION

Sensory Integration is the ability of the visual, vestibular and somatosensory

system to quickly send signals to the brain so the postural muscles can

respond quickly to changes in the environment

When one system is weak the body will begin to rely on another system,

even if the information it’s receiving is inaccurate.

The purpose of sensory integration is to get all the systems working together

and to re-train the brain to choose the most appropriate system to rely on

under any given situation.

The treatment strategy is to stimulate the weak system and then require it to

work in the absence of the other systems until it becomes stronger and all

the systems function together optimally.

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VIDEO

BALANCE ON WEDGE IN LOW LIGHT

SIT TO STAND AND GAIT WITH WEIGHT SHIFT

GAIT WITH GAZE STABILIZATION

GAIT WITH HEAD TURNS

GAIT WITH HEAD NODS

STEP UPHILL

STEP DOWNHILL

FUNCTIONAL ACTIVITY

Sensory Integration for Functional

Improvement

Case Study

49 yo female with cerebral palsy, who underwent laparoscopy and due to

complications was hospitalized for 6 weeks. Her primary caregiver is her 74 yo mother. Upon discharge from the hospital the patient was max assist for

transfers and required assistance for dressing, bathing and getting her meals.

High fall risk and unable to stay at home alone.

PLOF: w/c bound x 8 years but (I) in all transfers, (I) in bathing and dressing and

(I) is getting her breakfast and lunch on the days her mother worked. Able to stay at home alone for 4-5 hours while her mother worked part-time.

SUMMARY AND QUESTIONS

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Thank You!

Theresa Palkovic, PT

tpalk10115@aol.com

CASE STUDY

Evaluation Findings:

Patient was ambulatory until 8 years ago when she awakened one day and told her family she could not walk any more because she was afraid she would fall. From that time on she refused to ambulate; the family had to finally get her a w/c for mobility. Eventually she resumed sit to stand and stand pivot transfers and she was able to stand at the kitchen counter or bathroom counter for ADLS/IADLS.

Pertinent Findings:

1) Head held to the left; would not turn head to the right , turned body instead.

2) SW- 2/10, with peripheral edema in both lower legs

3) DVA (+), Saccades (+), VOR (+), Head Thrust (+) to the right, Dix-Halpike (+) for right canalithiasis

4) Plantarflexion contractures >15* bilaterally

5) Max assist for w/c transfers

6) (I) rolling left but refused to roll right

7) Unable to stand or ambulate

8) Core weakness

CASE STUDY

Interventions

1) Epley to correct Canalithiasis; gaze stabilization exercises, habituation

exercises, VOR exercises

2) Infrared light therapy to lower legs to improve circulation and sensory

stimulation to both feet

3) Joint mobilization, myofascial release, passive and active stretching

4) Postural strengthening exercises

5) Transfer training

6) Dynamic and static balance activities with focus on sensory integration

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CASE STUDY

OUTCOME

The patient was able to resume (I) transfers, (I) ADLS of dressing and bathing and

she was able to resume staying alone for 4-5 hours a day while her mother was at work.