1. Fall Risk Reduction Program Designing an Exercise Program Module #3 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 & 2  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  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

3. Fall Risk Reduction Program: Module 3  In this module, we will delve further into patient assessment. You have identified patients at risk for falling and evaluated performance under dual task conditions. Now you must further do further assessment to identify the system(s) of balance most responsible for the falls, and develop an plan of care to address the system(s).  Agenda  Screening & Assessing Balance Impairments: Information to gather in order to design an exercise program  Exercise selection  Designing a program  In this module, we will delve further into patient assessment. You have identified patients at risk for falling and evaluated performance under dual task conditions. Now you must further do further assessment to identify the system(s) of balance most responsible for the falls, and develop an plan of care to address the system(s).  Agenda  Screening & Assessing Balance Impairments: Information to gather in order to design an exercise program  Exercise selection  Designing a program

4. Agenda  Screening & Assessing Balance Impairments: Information to gather in order to design an exercise program  Exercise selection  Designing a program  Screening & Assessing Balance Impairments: Information to gather in order to design an exercise program  Exercise selection  Designing a program

5. Multifactorial Risk Assessment  Focused History  Physical Examination  Functional Assessment  Environmental Assessment  Focused History  Physical Examination  Functional Assessment  Environmental Assessment American Geriatric Society Clinical Practice Guidelines: Prevention of Falls in Older Adults

6. Multifactorial Risk Assessment: Focused History  History of falls – need detailed description of the fall circumstances, frequency, symptoms  Medication review  History of risk factors – acute & chronic medical issues  History of falls – need detailed description of the fall circumstances, frequency, symptoms  Medication review  History of risk factors – acute & chronic medical issues

7. Multifactorial Risk Assessment – Physical Exam  Physical function - Gait, balance (including postural reflexes), mobility, and lower extremity joint function  Neurological function – Cognitive evaluation, peripheral nerve function, proprioception, reflexes, and tests of cortical, cerebellar, & extrapyramidal function  Muscle strength  Cardiovascular status – Heart rate, postural pulse, blood pressure  Visual acuity  Vestibular function (oculomotor tests, positional testing)  Examine feet and footwear  Physical function - Gait, balance (including postural reflexes), mobility, and lower extremity joint function  Neurological function – Cognitive evaluation, peripheral nerve function, proprioception, reflexes, and tests of cortical, cerebellar, & extrapyramidal function  Muscle strength  Cardiovascular status – Heart rate, postural pulse, blood pressure  Visual acuity  Vestibular function (oculomotor tests, positional testing)  Examine feet and footwear

8. Multifactorial Risk Assessment – Functional Assessment  Assess activity of daily living (ADL) skills  Perceived functional ability and fear of falling  Assess activity of daily living (ADL) skills  Perceived functional ability and fear of falling

9. Multifactorial Risk Assessment – Environmental Assessment  Home safety  Other environment factors as needed  Home safety  Other environment factors as needed

10. Turning the multifactorial risk assessment into an exercise program – What to do with all this information?

11. Stratify the Patient Problems into Systems of Balance  Musculoskeletal System  Proprioceptive System  Oculomotor System  Vestibular System  Cognition/Communication  Musculoskeletal System  Proprioceptive System  Oculomotor System  Vestibular System  Cognition/Communication

12. Musculoskeletal System  Muscle, tendons, ligaments, bones, joints, and associated tissues that move the body and maintain form  Key muscle groups associated with walking and upright balance reactions:  Hip flexors  Hip extensors (especially gluteous maximus)  Hip Abductors (especially gluteous medius)  Knee extensors (quadricepts  Knee flexors (hamstrings)  Plantarflexors (gastrocnemius, soleus)  Dorsiflexors  Upper and lower abdominal muscles

13. Proprioceptive System  Proprioception is the unconscious awareness of body position.  It tells us about the position of our body parts in relationship to each other and the environment.  It allows us to have a knowledge of how much force and speed the muscle is required to generate in order to accomplish a specific movement which results in appropriately graded muscle control.

14. Oculomotor System  Is the control system that coordinates the 12 muscles which accurately direct our eye movements.  Three main types of Oculomotor Skills:  Saccades – The ability to quickly and accurately make eye movements or jumps from one target to another.  Fixation – The ability to maintain steady visual attention on a target.  Pursuits – The ability to smoothly follow a moving target.

15. Vestibular System  System of the body that is responsible for spatial orientation and balance.  The vestibular system sends information to the brain about the location of one's head in space.

16. Vestibular, Oculomotor, Proprioception Systems: Need at least two  In order to maintain balance, at least two of these systems must be sending balance information to the brain at any time.  Examples:  If in the dark, brain can use proprioceptive and vestibular inforamation to remain upright against gravity.  If have lower extremity amputation, can use vestibular and oculomotor systems.  If have labrynthiasis impacting vestibular system, can use oculomotor and proprioceptive information.

17. Cognition & Communication Systems (involved in dual tasking)  Cognition is the ability to think and process information  Attention, memory, processing, problem solving, judgment, impulse control, and executive skills.  Communication is the ability to exchange and comprehend language.  Naming, word finding, following directions, answering questions, speaking, and writing.  How much of the “cognitive pie” does mobility take? If maintain balance “hogs” resources, decreases cognitive and communication skills.  Places person in an either/or situation – can maintain balance or focus on cognitive task.  Cognition is the ability to think and process information  Attention, memory, processing, problem solving, judgment, impulse control, and executive skills.  Communication is the ability to exchange and comprehend language.  Naming, word finding, following directions, answering questions, speaking, and writing.  How much of the “cognitive pie” does mobility take? If maintain balance “hogs” resources, decreases cognitive and communication skills.  Places person in an either/or situation – can maintain balance or focus on cognitive task.

18. Sample Patient Problem List MusculoskeletalProprioceptionOculomotorVestibularCognition Peripheral NeuropathyX Lower extremity strength rated 3/5 X Flexed postureXXX Inadequate footwearX Decreased visual acuity due to diabetic retinopathy X Decreased problem solving skills X Impaired balance reactions XXX

19. Now that you have stratified the problems into the systems of balance, you can design a plan of care that incorporates Interactive Metronome

20. Why include Interactive Metronome in the plan of care?  Movement Requires Directed attention  Pathologies that disrupt motor timing and sequencing lead to inaccurate movements  IM & Dual Tasking  IM requires a patient to focus on auditory stimuli and make a motor response to hit the trigger on the beat.  Must decide if need to slow down, speed up, or remain consistent.  Computer can measure performance in milliseconds, so act at same speed as muscular contractions.  Helps patients identify their own timing tendency and learn how to counteract own tendencies.  Movement Requires Directed attention  Pathologies that disrupt motor timing and sequencing lead to inaccurate movements  IM & Dual Tasking  IM requires a patient to focus on auditory stimuli and make a motor response to hit the trigger on the beat.  Must decide if need to slow down, speed up, or remain consistent.  Computer can measure performance in milliseconds, so act at same speed as muscular contractions.  Helps patients identify their own timing tendency and learn how to counteract own tendencies.

21. Fall Risk Reduction Program Exercises  This library of exercises are suggestions. Concept is to design exercises, using the Interactive Metronome that target specific problem areas  Center treatment interventions around long and short term goals that are important to the patient. Goal selection was discussed in the second module  Download can be found on course materials page  This library of exercises are suggestions. Concept is to design exercises, using the Interactive Metronome that target specific problem areas  Center treatment interventions around long and short term goals that are important to the patient. Goal selection was discussed in the second module  Download can be found on course materials page

22. Musculoskeletal System Exercises *Photos and exercise descriptions available on course materials page

23. Proprioceptive System Exercises *Photos and exercise descriptions available on course materials page

24. Oculomotor System Exercises *Photos and exercise descriptions available on course materials page

25. Vestibular System Exercises *Photos and exercise descriptions available on course materials page

26. Cognition/Communication System Exercises *Photos and exercise descriptions available on course materials page

27. Fall Risk Reduction Poster Overview

28. Fall Risk Reduction Best Practices Kit  Contains:  1 – STOOP Board (12” x 18”)  5 – Fill-in-the-Blank Cards (4” x 11”)  5 – Melodic Intonation Cards (4” x 11”)  15 –Object Cards (7½” x 6”)  1 set – 1 – 12 Numbered Cards (8½” x 4”)  1 set – Yes/No Cards (4” x 8½”)  1 set – 1 – 25 Numbered Cards (4” x 3”)  15 – Word Cards (2½” x 3)  1 set – Various Sized Squares  Contains:  1 – STOOP Board (12” x 18”)  5 – Fill-in-the-Blank Cards (4” x 11”)  5 – Melodic Intonation Cards (4” x 11”)  15 –Object Cards (7½” x 6”)  1 set – 1 – 12 Numbered Cards (8½” x 4”)  1 set – Yes/No Cards (4” x 8½”)  1 set – 1 – 25 Numbered Cards (4” x 3”)  15 – Word Cards (2½” x 3)  1 set – Various Sized Squares

29. 1 – 12 Numbered Cards Object Cards STOOP Board Word Cards Various Sized Squares 1 – 25 Numbered Cards Yes/No Cards Fill-in-the- Blank Cards Melodic Intonation Cards Integrating Kit Items for Fall Risk Reduction Tasks Toe Tapping Clock Visual Memory Memory Naming Picture Identification STROOP ActivitiesAlphabetizing SortingSequencingYes/No Questions Word Finding Melodic Intonation

30. "Homework"  Complete following worksheet to develop a plan of care for your patient. Use the same patient as in Module #2.

35. Post-test  Complete post-test to receive link for Module # 4 of 6

36. Materials Page  This video  PowerPoint  Module 3 Homework  Exercise Guide  Poster  Best Practices Kit  www.interactivemetronome.com/index.php/ fall-risk-coaching www.interactivemetronome.com/index.php/ fall-risk-coaching  This video  PowerPoint  Module 3 Homework  Exercise Guide  Poster  Best Practices Kit  www.interactivemetronome.com/index.php/ fall-risk-coaching www.interactivemetronome.com/index.php/ fall-risk-coaching

37. QUESTIONS? You can call or email us. We’re here to help!  Call 877-994-6776:  Opt. 3 – Education  imcourses@interactivemetronome.com  Opt. 5 – Technical Support  support@interactivemetronome.com  Opt. 6 – Clinical Support  clinicaled@interactivemetronome.com  Opt. 7 – Marketing  newsletter@interactivemetronome.com  Call 877-994-6776:  Opt. 3 – Education  imcourses@interactivemetronome.com  Opt. 5 – Technical Support  support@interactivemetronome.com  Opt. 6 – Clinical Support  clinicaled@interactivemetronome.com  Opt. 7 – Marketing  newsletter@interactivemetronome.com