Mrs. Xavier was admitted to a hospital following a fall that resulted in a pelvic fracture. She has fallen several times prior because of dizziness, but has never hurt herself. She has a walker, but she prefers to walk with a standard cane. Mrs. Xavier will be hospitalized for a maximum of three days. What interventions can the therapist use to improve her balance during her hospital stay and upon discharge home?

Assessment of Fall Risk

Ambulating, stair climbing, and performing activities of daily living require good balance control and coordination between the body systems. As reviewed in the previous module, deterioration of these systems affects balance and increases the likelihood of falls. When evaluating a patient with a history of dizziness or falls, it is important to complete a formal balance assessment. Fortunately, several screening and functional assessment tools are available (see sidebar).

Screening and Functional Assessment Tools for Balance Static Balance Tests Parallel standing Semi-tandem standing Tandem standing Single-leg standing Romberg test Functional Assessment Tools Berg Balance Scale Tinetti Performance Oriented Mobility Assessment Timed Up and Go Dynamic Gait Index Modified Clinical Test for Sensory Interaction and Balance (CTSIB) Chair Stand Test Multidirectional Reach Test Functional Reach Test Fukuda Stepping Test Balance Screening Tool Sensory Oriented Mobility Assessment Instrument Activities-Specific Balance Confidence Scale Dizziness Assessment: Dizziness Handicap Inventory

Functional performance tests objectively measure an individual’s ability to maintain balance or ambulate.^1,2,3  Fall risk assessment tools can assist therapists in determining appropriate therapeutic interventions, allow healthcare providers to monitor meaningful balance changes, and may improve reimbursement by allowing practitioners to consistently document objective balance findings. Advantages of these tools include a lack of complex equipment, low cost, time efficiency, and practicality in different settings.

There is no single tool recommended for a particular practice setting or patient population. When choosing functional assessment tools, the practitioner should select the test that is the most practical, cost effective, and time efficient for the patient population and work environment.^2,3 Also, the tools should challenge the body systems responsible for postural control. Commonly utilized assessment tools and their work applications are listed in the following sidebar.

Setting-Specific Balance Tools   Acute Hospital Morse Falls Scale STRATIFY Risk Assessment Tool Hendrich Falls Risk Model II Skilled Nursing Facilities Mobility Interaction Fall Chart Dontown Tinetti Balance Subscale Area Ellipse of Postural Sway Community Setting (Homecare and Outpatient) Five-Minute Walk Test Functional Reach CTSIB BBS

This list is not all inclusive, and certain tools can be utilized in different practice settings. To date, there are no published systematic reviews that assess the psychometric properties and practical applications of functional balance tests in community-dwelling older adults.⁴ Such a review would help practitioners decide which tools would be the most useful when assessing patients’ balance. However, the BBS and TUG are considered to be reliable and valid for community-dwelling older adults.⁴ The BBS does not have a gait component; however, because of its reliability, validity and wide use, it is considered the gold standard.⁵

Fall-Related Efficacy

Fall-related efficacy, defined as perceived self-efficacy or confidence at avoiding falls, is associated with functional status. Women are affected more than men.⁶ Increased fear of falling results in self-limitation of activities, functional decline, and a loss of independence without any actual physical impairments.⁶ Self-limitation of activity results in further patient deconditioning, isolation, depression and decreased quality of life.⁷ Literature indicates that exercise can improve balance confidence, which results in improved fall-related efficacy.6

Fall Risk Guidelines

There are several fall prevention guidelines for older adults that will lead physicians to refer patients to physical therapy for balance and falls assessments. Adults with recurrent falls, gait abnormalities, or noted balance impairment should receive a fall evaluation by a clinician such as a physical therapist.⁸ Multimodal and multifactorial interventions⁹ should include, but are not limited to, medication reduction, home modification, exercise, balance training, and physical therapy intervention.^10,11 It is recommended that long-term care facilities implement fall prevention programs, staff education, and ongoing patient monitoring.¹⁰

A 2009 Cochrane review determined that multifactorial health and fall intervention screens should be completed with older adults living in facilities or the community. It recommended a withdrawal of psychotropic medications to decrease fall risk. In addition, the review recommended strengthening and balance training programs in the home environment, home assessment and modification, cardiac pacing, and tai chi to further decrease fall risk.¹²

A 2010 review that focused on older adults living in the community recommended an interdisciplinary approach to care, tai chi, medication reduction, and a progressive strengthening and balance training program; however, exercise parameters were not established.¹¹ A 2010 guideline provided a clinical algorithm for fall risk assessment and emphasized the importance of a multifactorial fall risk assessment for adults who report difficulties with gait or balance, whether or not there was a history of falls.¹³ Recommendations for examination are included in the following sidebar. Physical therapists are in a unique position to complete fall risk assessment and provide appropriate patient intervention.

Recommendations for Fall Risk Assessment (AGS/BGS Guideline) Assessment Frequency of falls, symptoms prior to fall, injuries from fall Determination of patient’s perceived functional ability and fear of falling Assessment of postural hypotension — management as needed Examination of feet and footwear — intervention or referral as needed Functional assessment — referral or intervention as needed Environmental/home safety assessment and modification Exercise programs (for community-dwelling adults) that incorporate balance, gait, flexibility, endurance, coordination and strength training Exercise programs 1-3 times per week, minimum of 12 weeks, variable intensity Tai chi and physical therapy Group sessions or individual programs Medication/Supplementation Medication reduction/withdrawal Calcium and Vitamin D supplementation Cardiac pacing for adults with cardioinhibitory carotid sinus hypersensitivity

In addition to the aforementioned guidelines, the Agency for Healthcare Research and Quality (through the National Guideline Clearinghouse) offers guidelines for the assessment, prevention, and management of patient falls and fall risk on its website. Furthermore, it provides information on the prevention of fall injuries and patient falls in the acute care setting and the long-term care environment.¹⁴

Fall Risk Intervention

Therapists must identify the reason for patient falls to determine an appropriate plan of care. Physical therapists can treat modifiable risk factors and educate patients on how to compensate for fixed deficits (such as impaired proprioception and sensation).  Patient education also includes education on home modifications (installing appropriate lighting and grab bars, removing tripping hazards), appropriate footwear, side effects of medications, safe use of medical equipment, and available community resources. Visual deficits can be addressed by educating patients on routine eye examinations and appropriate follow-up. The Safe Steps Program created by the Home Safety Council, an organization dedicated to the prevention of home injuries, advocates for older adults to participate in regular exercise, track medications, and review tips for home modification.¹⁵ One study about fall risk concluded that exercise had a positive effect on fall reduction compared with other interventions¹⁶ and decreased fall risk by 35% to 45%.¹⁷ An exercise program should include strengthening and stretching of major muscle groups (hip extensors and abductors, knee extensors, ankle dorsiflexors and plantar flexors, shoulders, biceps and triceps, abdominals, and back extensors), aerobic training, and balance training. Exercises should incorporate reflexes and challenge the limits of stability. Strengthening results in enhanced muscular control, which may improve joint proprioception.¹⁸

Patients are likely to score higher on functional assessment tools following physical therapy intervention; however, there appears to be no direct change in fall-related efficacy. This may be because some therapists focus on balance exercises and do not combine balance exercises with functional activities. The difficulty of balance exercises for patients can be increased by altering standing surfaces (using a balance pad or ambulation on an uneven surface), altering the speed and direction of the activity, adding physical load to the exercise, incorporating sudden postural transitions (sudden start and stop), altering the patient’s base of support (e.g., single-leg stance), reducing the patient’s sensory input (e.g., eyes closed), and reducing the level of assistance provided to the patient. Challenging balance activities can result in improvements in fall-related efficacy. In addition, alternative or holistic treatment approaches such as tai chi, yoga, Feldenkrais, and Pilates may improve patient balance and decrease fall risk. Research has demonstrated that tai chi decreases fall risk and benefits patients with vestibular dysfunction.^{19, 20}

Over the last few years, there has been an increase in the use of technology to challenge patients’ balance in therapy. Products such as the Nintendo Wii^® and rehab-specific balance equipment, such as the Korebalance^®, provide immediate static and dynamic balance results to patients. This technology improves balance and performance by providing immediate visual feedback and cues.

Therapists should refer to the aforementioned fall prevention guidelines for greater information on patient education. In addition, a falls toolkit, designed by the U.S. Department of Veterans Affairs National Center for Patient Safety, provides further information on fall prevention, interventions for fall management, and patient and family education on fall risk.²¹

There are several challenges to creating balance programs for older adults, including patient adherence to a program, time constraints for practitioners and patients, inadequate reimbursement, competing patient or therapist demands, and the difficulty of managing patients with multiple health problems.¹¹

Vestibular-Specific Assessment

When taking a history in older adults at risk for falls with suspected vestibular dysfunction, it is important to obtain specific information that can help to establish a diagnosis — for example, frequency and circumstances of falls, current level of function, test results, and current symptoms including presence of dizziness and/or disequilibrium should be obtained.^22,23 Medications that may contribute to as well as reduce dizziness (e.g., meclizine, which may limit the extent of vestibular rehabilitation) are important to note.²¹ Differentiating between vertigo (feeling of spinning), dizziness (general feeling of disorientation or lightheadedness), and disequilibrium (feeling of imbalance), as well as further description of symptoms such as frequency, duration, and exacerbating factors (motion or positional changes) can be helpful.²² There are many available questionnaires that can further measure the patient’s perception of the effect of dizziness and/or disequilibrium during activities of daily living, e.g., the Dizziness Handicap Inventory and Activities-Specific Balance Confidence Scale.²³

If vestibular pathology is suspected, the examination should include an oculomotor exam, positional provocation testing (e.g., Dix-Hallpike maneuver) if distorted peripheral dysfunction is suspected, and vestibulospinal reflex (VSR) function testing during standing and locomotion. An oculomotor exam should include ocular alignment, smooth pursuits, saccades, vestibular ocular reflex (VOR) function via gaze stability and dynamic visual acuity, VOR cancellation (ability to suppress the VOR), and presence of nystagmus.^22,23

Gaze stability is tested by having the patient maintain a fixed gaze on a target while moving his or her head horizontally and vertically. It can also be tested with the rapid head thrust test, in which the clinician manually rotates the patient’s head right and left quickly while the patient maintains a fixed gaze on a target. Impaired VOR on either test is signified by deviation of the patient’s gaze from the target or “catch-up saccades,” in which the patient’s eyes deviate from the target and then return to the target in small intervals. For example, if a patient moves his or her head to the right, deviation of the eyes from the target to the right would indicate an impaired right-sided VOR. Impaired VOR can result in diminished visual acuity during head movements due to retinal slipping.²⁴

Dynamic visual acuity can be tested by assessing the patient’s ability to clearly read letters on an eye chart 20 feet away during head rotations at a speed of 2 Hz.²² The patient reads the smallest line that he or she is able to see clearly with a static head position, and then with head rotations. A difference of more than two lines indicates impaired VOR function. VOR cancellation is tested by having the patient follow a moving target while moving his or her head simultaneously.²²

Nystagmus can occur normally with end-range eye movements. Pathological nystagmus can include bilateral gaze-evoked nystagmus (eyes beat upward with upward gaze and down with downward gaze) that can occur with central vestibular lesions; unidirectional horizontal nystagmus that can occur in unilateral peripheral dysfunction; and position-induced nystagmus that can occur with benign paroxysmal positional vertigo and with central vestibular lesions. Some presentations of nystagmus may require specialized equipment to be detected (for example, Frenzel lenses).²²

Positional vertigo can occur in both central and peripheral vestibular dysfunction. The typical presentation of central lesions is vertigo that starts upon assumption, persists for the entire duration in the provoking position, and does not fatigue with multiple repetitions.²⁵ In contrast, the classic presentation for the BPPV type of peripheral dysfunction is a period of 1 to 40 seconds of no symptoms, followed by symptoms that include nausea, vertigo, and nystagmus that beats toward the side of involvement with an upward torsional component. Canalithiasis-type BPPV symptoms usually last for 30 to 60 seconds, while cupulolithiasis-type BPPV symptoms usually last for more than one minute and then resolve.²⁵ BPPV symptoms also typically fatigue after multiple repetitions of the provoking position.²⁶

The Dix-Hallpike maneuver is used to test for posterior canal BPPV, which occurs in 63% of cases of BPPV.²⁴ (Other test positions are required for anterior and lateral canal BPPV.) In the Dix-Hallpike maneuver, the patient is moved quickly from a sitting position with the head rotated 45 degrees toward the side being tested to supine with the head extended 30 degrees while being held off the treatment table. Vertebral artery testing should be performed prior to initiating the maneuver so appropriate modifications can be made to the test position, such as putting the table in a Trendelenberg position to avoid neck hyperextension. If there is a positive finding, canalith repositioning maneuvers such as the Epley maneuver for posterior canal canalithiasis can be performed.²⁶ (Canalith repositioning maneuvers will be discussed further in this module). If patients with BPPV report disequilibrium and/or unsteady gait, postural stability and balance should also be assessed.^24,26

VSR function can be evaluated during standing and locomotion, as well as with standardized balance measures. Standing balance can be assessed with the Romberg test, tandem standing, and single-leg stance, and also during dynamic standing activities and during gait.²² The Modified CTSIB can be used to evaluate which of the systems involved in balance are affected by varying sensory conditions.²² The Fukuda Stepping Test, where the patient marches in place 50 times with eyes closed, can be used to evaluate dynamic standing balance.²² Patients with unilateral vestibular lesions may turn toward the side of the lesion during the test, while patients with bilateral vestibular dysfunction may fall.²² Computerized dynamic posturography (if available) can also assess postural stability in varying conditions; however, performance is not necessarily related to frequency of falls.²⁷ Observational gait analysis and/or evaluation tools such as the Dynamic Gait Index can be used to assess postural stability, balance, and coordination during gait. The DGI includes walking with head rotation, which can be used to assess VOR function.²² The DGI has been shown to be an appropriate measure of fall risk in the vestibular population.²⁷ Numerous other balance tests can be utilized dependent on the patient’s complaints, accompanying impairments and/or endurance.

Vestibular-Specific Intervention

Vestibular rehabilitation exercises aim to reduce symptoms and improve postural stability via habituation, adaptation, or substitution.²⁷ Habituation refers to diminishing the vestibular system’s response to a stimulus via repeated exposure to the stimulus. For example, patients with motion-induced or positional vestibular symptoms are given multiple repetitions of exercise using the provoking movement or position; the goal is to reduce symptoms as a result of habituation by the central nervous system. Habituation has been most effective in unilateral peripheral disorders. It has been somewhat effective in central vestibular disorders, and the least effective in bilateral peripheral vestibular disorders.²⁷ Adaptation refers to long-term adjustments of the vestibular system’s motor output system in response to erroneous information (e.g., retinal slip).^22,27 Patients with impaired VOR may be given gaze stabilization exercises that involve moving the head while attempting to maintain a fixed gaze on a target. The exercises aim to cause adaptation in response to repeated retinal slipping sensed as error signals, with the eventual goal of improving gaze stabilization.^24,29 Substitution exercises teach patients to use alternative strategies to compensate for impaired vestibular function, particularly in patients with bilateral peripheral involvement who do not have the available function required for habituation or adaptation.^24,28 Patients with bilateral peripheral dysfunction and impaired VOR can be taught to use the cervical ocular reflex, smooth pursuits or saccades instead of VOR for gaze stabilization.

There is strong evidence for the use of vestibular rehabilitation in unilateral peripheral disorders.²⁹ Exercises are prescribed based on examination findings. For example, gaze stabilization exercises as described previously can be prescribed for impaired VOR. Patients should practice moving the head both horizontally and vertically as quickly as they can while still maintaining the target in focus. Difficulty can be graded by increasing the speed of head oscillations, making the conditions more dynamic (e.g., head and target both move in opposite directions as opposed to the target being static), having the patient perform them in more challenging postures (e.g., supine, sitting, standing or walking), and increasing the duration and/or repetitions of the exercise. Patients may start doing the exercises for 30 seconds, two to three times per day, and progress to one minute, four to five times per day.²⁷ gaze stabilization exercises can also improve postural stability because of the contribution of visual cues to balance.²⁴

There is strong evidence for the use of canalith repositioning maneuvers for the treatment of canalithiasis BPPV. In canalith repositioning, patients maneuver the head and trunk through a sequence of positions to mobilize debris out of the involved semicircular canal.³⁰ For example, the Epley maneuver is used for the treatment of posterior canal BPPV. After a positive finding has been elicited during the Dix-Hallpike maneuver, the Epley maneuver can be performed immediately from the same position. The patient is moved from sitting to supine with his or her head extended 30 degrees and rotated 45 degrees toward the affected side for 2 to 3 minutes. Then the patient’s head is slowly rotated to the opposite side. He or she is assisted into sidelying while maintaining his or her head in the position for 2 to 3 minutes, and then assisted into sitting.^22,24 Because recurrence rates are high, canalith repositioning maneuvers may need to be repeated.^22,24 Patients can be given home exercises to perform self-canalith repositioning.

There is positive but limited evidence for the use of Brandt-Daroff exercises, and the least available evidence for using the Semont maneuver.³⁰ Brandt-Daroff exercises were developed for cupulolithiasis BPPV, based on the theory that debris caught in the cupula is dislodged during the exercises.^24,26 The patient moves rapidly from sitting into sidelying on the affected side, maintains the position for 30 seconds after vertigo stops, moves into sidelying on the opposite side for 30 seconds, and then back up to sitting. The maneuver is repeated 5 to 20 times, 2 to 3 times per day, until the patient is asymptomatic for 2 days.^24,26 The Semont maneuver was also developed for cupulolithiasis BPPV. The patient is moved rapidly from sitting into sidelying with the affected ear down for 2 to 3 minutes.^24,26 He or she is then moved to sidelying on the opposite side for 5 minutes, and finally assisted to sit up.^24,26

Balance and postural stability training should be prescribed to all patients with vestibular dysfunction based on specific impairments.²³ Exercises should be multimodal, making use of one or more of the three sensory systems used in balance.^22,23,27,28 Conditions should be varied by using different surfaces, base of support, static versus dynamic activities, eyes open versus eyes closed, and static head position versus head rotation, depending on the individual’s impairments.^22,23,27,28 Patients can also be taught strategies for balance recovery, e.g., hip versus ankle strategy.^22,27 Patients should practice balance during functional activities as well as during walking.^22,28 Practice should take place in various types of environments, including busy environments with obstacles to maneuver as well as ramps and curbs to negotiate.^22,27 Patients can practice making turns while walking, gradually making faster and sharper turns.²⁷ VOR retraining can be incorporated by having patients practice head turning and gaze stabilization activities during standing and walking.^27,28

Vestibular exercises are also effective for bilateral peripheral disorders. Substitution exercises as described above are indicated for these patients. For example, a patient with impaired gaze stability and bilateral vestibular dysfunction would be prescribed exercises to practice saccadic or smooth pursuit eye movements or to use the cervical-ocular reflex to maintain gaze on a target during low-frequency head movement.³⁰ Saccade training involves having the patient practice looking from one target directly to a second target and then turn his or her head to the target. The imaginary target exercise may be used for COR training or to foster central preprogramming. Patients focus on a target, close their eyes, turn their head while trying to maintain their gaze on the target with closed eyes, and then open their eyes to see if they have maintained their gaze successfully on the target.²⁷ Patients with disequilibrium due to bilateral dysfunction are taught to use visual or somatosensory systems for balance, as well as compensatory strategies for recovery of balance.^27,32

While there is less evidence to support vestibular rehabilitation for central vestibular disorders, the available evidence suggests that vestibular rehabilitation interventions, such as substitution strategies, adaptation training, and balance and gait training, are beneficial in improving functional limitations caused by dizziness and imbalance as a result of vestibular dysfunction of central origin.^22,33

Effect of Vestibular Rehabilitation on Fall Risk

Evidence demonstrates that the incidence of falls in patients with vestibular dysfunction is related to the degree of vestibular loss more so than to age.²⁷ In addition, limited evidence on the effect of vestibular rehabilitation on fall risk suggests that outcomes depend on the extent of vestibular dysfunction.²⁷ Patients with unilateral peripheral vestibular loss show improvements in fall risk after a vestibular rehabilitation program, while patients with bilateral vestibular loss show little improvement.²⁸

Conclusion

Physical therapists are well suited to diagnose and treat patients with a history of falls, fall-related injuries, or vestibular dysfunction. PTs should be aware of available fall and vestibular-specific assessment tools, guidelines, and evidence-based treatment programs to provide an optimal level of care to their patients. As more individuals seek physical therapy services as part of direct access, it is essential for clinicians to remain current in the literature and update their clinical skills accordingly to achieve better patient outcomes.

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