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Balance Testing in Older Adults

Balance Testing in Older Adults. Alicia Burillo Ithaca College Clinical Affiliation #2 February 24, 2011. Postural Assessment Scale for Stroke Patients (PASS). Maintain equilibrium -rolling from supine to paretic side -rolling from supine to nonparetic side

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Balance Testing in Older Adults

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  1. Balance Testing in Older Adults Alicia Burillo Ithaca College Clinical Affiliation #2 February 24, 2011

  2. Postural Assessment Scale for Stroke Patients (PASS) • Maintain equilibrium • -rolling from supine to paretic side • -rolling from supine to nonparetic side • -supine to sitting at edge of mat • -sitting at edge of mat to supine • -sit to stand • -stand to sit • -standing, picking up a pencil from floor Measures: • Ability to maintain a given posture. • Ability to maintain equilibrium during a change in posture. • Maintaining posture - Sitting without support -Standing with support -Standing without support -Standing on nonparetic leg -Standing on paretic leg

  3. Dynamic Gait Index • 8 tasks of gait, including: • Walking on a level surface • Changing gait speed • Ambulation with horizontal head turns • Gait with vertical head turns • Gait and pivot turn • Stepping over objects • Step around objects • Stair negotiation Helps to identify specific gait impairments and risk of falling. http://www.youtube.com/watch?v=Rbq7SnsRyQk

  4. Dynamic Gait Index • Score interpretation • Max of 24 points ( higher the score the better) • ≤ 19: related to falls in older adults • Score of 21 +/- 3: mean score for healthy older adults • Score of 11+/-4: mean score for older adults with a history of falls and imbalance

  5. 4 Square Step Test What is it used for? Predicts fall risk Ability to step in multiple directions Ability to step over low objects Stepping forwards, sideways, and backwards (Higher function) Memory and Speed (sequence)

  6. Advantages of 4 Square Step Test • Quick to Perform • Can be used as a treatment technique • May perform with an assistive device • High sensitivity and specificity (highly accurate measure to predict falls)

  7. 4 Square Step Test cont. • What to look for during the test…. • Both feet must make contact in each square • Subject must remain facing same direction • Cannot touch sticks • Timing starts when the first foot makes contact in square #2 • Look for hesitancy to move sideways or backwards • Change in speed when moving in different directions • Visual dependency (watching feet instead of looking up) • Gait deviations • Balance difficulties

  8. Functional Reach Test Purpose: To assess anterior-posterior stability via reaching forward. -Measures fall risk and frailty -Can be performed in a variety of settings -Little or no equipment is required -Can be completed in less than 5 min.

  9. How to perform the Functional Reach Test • Have subject stand and reach forward as far as he can • First have patient raise both arms to shoulder level and then lower outside arm and make fist with raised arm in order to prevent protraction or rotation of the trunk from occurring during reaching. • Measure starting point from 3rd metacarpal of raised arm. • Both feet must stay behind the line. Patient can raise onto their toes and/or bend trunk as long as he does not move his feet.

  10. How to interpret the Functional Reach test • <6” : Limited balance and typically unable to ascend and descend stairs in a reciprocal pattern, and 4x more likely to have 2 falls in next 6 months. • 6-10” : 2x more likely to have 2 falls in the next 6 months. • <7.11 : Physically frail • 10” or greater: Normal

  11. Functional Reach Norms Duncan PW, Weiner DK, Chandler J, Studenski S. Functional reach: a new clinical measure of balance. J Gerontol 1990; 45:M195.

  12. Physical Performance Test (PPT) Activities: Write a sentence Simulated eating (place 5 kidney beans in a bowl) Lift a book & put it on a shelf Put on & remove a jacket Pick up a penny from floor Turn 360° 50-foot walk test Climb 1 flight of stairs Climbing flights of stairs (max of 4 flights) • Measures physical function and ADL’s • Each of the 9 items are timed except #6 & #9 • Each item is scored on a 0-4 scale, with 4 being the best score

  13. Modified PPT Similar to PPT but replaces 2 measures of hand function with tests of balance and leg strength. Measures aspects of physical function and ADL’s in older adults. Can be done in any order; each item is timed except #6, & #8. An assistive device may be used for walking and stair climbing. #4: 50-foot walk – 50feet in 15sec. = 1.0m/sec; Gait speed = D/T; gait speeds >0.88m/sec are required for community ambulation.

  14. Short Physical Performance Battery (SPPB) • Assesses tasks that require leg function and ADL’s • Assesses mobility, disability, future disability, hospitalization, & death. • Early identification allows for early intervention. • Use exact wording when performing the test (standardization) visit http://www.grc.nia.nih.gov/branches/ledb/sppb/index.htm. • Must be able to stand unassisted and without assistive device. • 3 parts: balance tests, gait speed test, chair stands test. (must be done in order)

  15. Chair Stand Test • Tests chair riseability, LE strength (quads) • Difficulty rising from a chair is a common complaint of older adults. • Established norms so can compare performance against other individuals. • Predicts risk of functional decline. • 3 versions: 30 sec., timed 5 reps, timed 10 reps.

  16. Chair stand test cont. • 30 sec. chair stand • Stand as many times as possible in 30 sec. • If cannot complete 1 rep without using arms, score= 0 • Timed 5 rep and 10 rep • More appropriate for frail individuals • Requires completion of at least 1 rep without using arms or score=0 • Takes less time than the 30 sec chair stand.

  17. Chair Stand Test

  18. Clinical Test of Sensory Interaction on Balance (CTSIB) or Foam and Dome Test • Tests visual, vestibular, & somatosensory input on standing balance. • 6 conditions: • Firm surface (floor) • Eyes open • Eyes closed • Wearing conflict dome • Compliant surface (foam) • Eyes open • Eyes closed • Wearing conflict dome

  19. Foam and Dome Test

  20. CTSIB cont. 30 sec. per trial 3 trials performed 90 sec. per condition 540 sec. is possible for a perfect test Foam pad-large enough to stand on comfortably & thick enough so feet are not flat on floor. Conflict dome- Chinese paper lantern to block person’s vision. A trial is finished when subject’s arms or feet change position.

  21. Activities-Specific Balance Confidence Scale (ABC) • Self reported Confidence Scale • The subjects are asked to rate their confidence in doing 16 items from being 0% confident to 100% confident. • The subjects rate their confidence that they will not lose their balance or become unsteady when they do each item. • Test-retest reliability =.92

  22. Activities-Specific Balance Confidence Scale • The 16 items are: • Walking around the house • Walking up or down the stairs • Bending over to pick up a slipper from the front of a closet floor • Reaching for a small can off of a shelf at eye level • Stand on your tip toes and reach for something above your head • Stand on a chair and reach for something • Sweep the floor • Walk outside the house to a car parked in the driveway

  23. Activities-Specific Balance Confidence Scale • Get into or out of a car • Walk across a parking lot to the mall • Walk up or down a ramp • Walk in a crowded mall where people rapidly walk past you • Are bumped into by people as you walk through the mall • Step onto or off of an escalator while holding onto a railing • Step onto or off of an escalator while holding onto parcels such that you cannot hold onto the railing • Walk outside on icy sidewalks

  24. Gait Speed Test Gait speed is the most sensitive measure of declining function and mobility. Predictor of frailty and nursing home placement. Predictor of ability to walk in the community. Can be tested with or without a device. Can test over any distance (as little as 4m).

  25. Gait Speed Test Should be able to change gait speed esp. if a community ambulator. Gait speed = D/T Subject walks 4m at normal pace. Average adult gait speed = 1.2m/s (speed at which traffic signals are set) Average gait speed of high functioning older adults = 1.75-2.25 m/s. Average gait speed of nursing home residents = <.5m/s.

  26. TUG (Timed Up and GO) The TUG tests general mobility Can be tested with and without an assistive device. Inter-rater reliability = 0.99 Patient stands from chair and walks at usual speed 3 meters to a mark on floor, turns, walks back and sits down. Fall Risk > 13.5 sec. >30 sec.: need for an assistive device for balance and functional activities.

  27. Tinetti or Performance Oriented Mobility Assessment (POMA) Measures balance and gait in older adults Predicts falls Scored on a 3 point ordinal scale (0-2) Total possible score of 28 Higher score = better performance Total balance score = 16 Total gait score = 12 High inter-rater reliability =.72-.86 (M.J. Faber, 2006) High test-retest reliability = .80-.93 (M.J. Faber, 2006) Valid to discriminate between ability to ambulate independently and needing an assistive device

  28. Tinetti cont. Cut off Scores for Fall Risk (Faber et al., 2006) T POMA = 19 B POMA = 10 G POMA = 9 T POMA = Total POMA B POMA = Balance POMA G POMA = Gait POMA

  29. References VHI Administering Functional Assessment Tests. The complete video series. Discs 1-3.

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