1. Fall Risk Reduction Program Grading the Task Module #4 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 -3  In the first module we reviewed the premise of the Fall Risk Reduction Program, including the inclusion criteria for patient selection  The second module reviewed patient assessment  Identifying patients at risk of falling  Evaluating patients in a dual task condition to simulate “real life” situations  The third module covered how to determine which systems of balance were weakest and develop an exercise program for those systems  In the first module we reviewed the premise of the Fall Risk Reduction Program, including the inclusion criteria for patient selection  The second module reviewed patient assessment  Identifying patients at risk of falling  Evaluating patients in a dual task condition to simulate “real life” situations  The third module covered how to determine which systems of balance were weakest and develop an exercise program for those systems

3. Module 4: Agenda  What IM scores mean  How to advance patient by modifying domains of challenge  Reassessment to gauge progress  What IM scores mean  How to advance patient by modifying domains of challenge  Reassessment to gauge progress

4. IM Scores: Task Average  Average number of milliseconds off the beat  Lower task average indicates improved motor planning and sequencing  Short and Long Form Assessments will provide a baseline task average. Repeat these assessments on regular basis to monitor progress.  Don’t use task average of exercises performed to determine if patient is improving because exercise difficulty can influence task average.  Average number of milliseconds off the beat  Lower task average indicates improved motor planning and sequencing  Short and Long Form Assessments will provide a baseline task average. Repeat these assessments on regular basis to monitor progress.  Don’t use task average of exercises performed to determine if patient is improving because exercise difficulty can influence task average.

5. IM Scores: Variability Average  Average number of milliseconds from one hit to the next; is a measure of precision.  Lower variability indicates more precise, calculated motor control  Variability average is comparing the patient to him or herself, rather than the reference tone  Average number of milliseconds from one hit to the next; is a measure of precision.  Lower variability indicates more precise, calculated motor control  Variability average is comparing the patient to him or herself, rather than the reference tone

6. IM Scores: Other Data  % Super-Right-On  Highest-In-A-Row  Burst  All these measures indicate consistency of hits and can be correlated with improved motor control and sequencing  % Super-Right-On  Highest-In-A-Row  Burst  All these measures indicate consistency of hits and can be correlated with improved motor control and sequencing

7. Fall Risk Reduction Program: Exercise Difficulty  In Module 3 we reviewed exercises that target each balance domain  Exercises can be made more or less difficult. Find that “sweet spot” for success – exercise is hard enough to challenge balance systems but doesn’t overly frustrate the patient?  Exercise should be performed at one “level” more difficult than person can perform safely or independently. Can also use task and variability average as a guide. Example: Patient clap hands rhythmically while seated but not standing, as indicated by task and variability average; Exercise difficulty should be focused on standing activities. Example: Patient can successfully perform IM if not distracted; Exercise difficulty can be increased by providing distractions (dual tasking)  In Module 3 we reviewed exercises that target each balance domain  Exercises can be made more or less difficult. Find that “sweet spot” for success – exercise is hard enough to challenge balance systems but doesn’t overly frustrate the patient?  Exercise should be performed at one “level” more difficult than person can perform safely or independently. Can also use task and variability average as a guide. Example: Patient clap hands rhythmically while seated but not standing, as indicated by task and variability average; Exercise difficulty should be focused on standing activities. Example: Patient can successfully perform IM if not distracted; Exercise difficulty can be increased by providing distractions (dual tasking)

8. Phase 1-3 Activities  Reminder: Patient needs to spend time in Phase 1-3 learning IM basics.  Amount of time spend in these phases dependent on patient’s learning curve.  Is the time they learn the “game” (i.e. when to hit trigger, what is the beat, what do guide sounds mean, etc.)  Begin IM exercises specific to balance systems in Phase 4  Reminder: Patient needs to spend time in Phase 1-3 learning IM basics.  Amount of time spend in these phases dependent on patient’s learning curve.  Is the time they learn the “game” (i.e. when to hit trigger, what is the beat, what do guide sounds mean, etc.)  Begin IM exercises specific to balance systems in Phase 4

9. Advancing the Exercises  Utilize that IM scores to determine how to grade the exercises  Task and variability average on Short Form Test or Long Form Assessment more important than scores on exercises  Difficulty of exercise can have significant impact on score  Use patient’s response to therapy to determine when and how to grade the task.  Frustration level  Success level  Amount of cuing needed  Retention of previous session  Utilize that IM scores to determine how to grade the exercises  Task and variability average on Short Form Test or Long Form Assessment more important than scores on exercises  Difficulty of exercise can have significant impact on score  Use patient’s response to therapy to determine when and how to grade the task.  Frustration level  Success level  Amount of cuing needed  Retention of previous session

10. Domains of Challenge Computer Challenge Extremity Challenge Postural Challenge Cognitive/Ling uistic Challenge Environmental Challenge

11. Domains of Challenge  Can manipulate five domains of challenge to make exercises more or less difficult  Rule of thumb - alter one domain at a time  Can manipulate five domains of challenge to make exercises more or less difficult  Rule of thumb - alter one domain at a time

12. Computer Challenge – Make an exercise easier or harder by adjusting...  Tempo speed  Volume of repetitions  Difficulty level  Volume  Guide Sounds  Burst goal(s)  Feedback

13. Extremity Challenge – Make an exercise easier or harder by adjusting...  Trigger placement  Triggers placed closed to center of mass are easier to hit than triggers placed further away Increase difficulty even more by requiring weight shift to reach, add weights or resistance bands  Trigger sequence  Hitting one trigger is easier than hitting multiple triggers Increase difficulty by creating patterns that incorporate both sides of body, cross midline, or alternate between hand and foot taps

14. Postural Challenge – Make an exercise easier or harder by adjusting....  Amount of postural support  Postural variations:  Supine  Sitting with back support  Sitting without back support  Sitting on unstable surface (physioball)  Standing  Standing on unstable surface (on floor mat, balance board)  Tandem stance on stable or unstable surface  Unilateral stance on stable or unstable surface

15. Cognitive/Linguistic Challenge – Make an exercise easier or harder by...  Combining a cognitive and IM task. Hit trigger while:  Naming objects  Digit recall  Answering questions  Mathematic manipulation

16. Environmental Challenge – Make an exercise easier or harder by adjusting....  Complexity of the environment  Quiet room  Dark room  Door open  In busy hallway  Outside  On sidewalk next to traffic  With background noise  Complexity of the environment  Quiet room  Dark room  Door open  In busy hallway  Outside  On sidewalk next to traffic  With background noise

17. Timing Tendency Strategy to Improve Performance Consistently VERY early (task average is 200-400 ms range) Increase tempo initially to go with patient’s timing tendency, then reduce over time, place distance between patient and trigger to build in distance and effectively delay hit. Consistently VERY late (task average is 200-400 ms range) Decrease tempo initially to go with patient’s timing tendency, then increase over time, hands on assistance, quiet environment to minimize cognitive distractions. Is it a movement issue or cognitive processing issue? If movement, is trigger within zone of available range of motion and strength? Hit randomly Whole body movements to beat, hands on assistance, increased proprioceptive input in time to beat, visual mode Hit opposite of beat Hands on assistance, modeling, visual mode to provide visual representation of the beat Score significantly worse with guide sounds Adjust difficulty level to easier setting, decrease volume of guide sounds, visual mode with guide sounds off (visual mode only), introduce guide sounds gradually by putting volume of some to zero. Difficulty focusing or participating Shorter exercises in the beginning then gradually lengthen.

18. Applying Domains of Challenge  Computer:  Easier or Harder -Increase or decrease tempo  Extremity  Easier -Use only one mat  Easier -Place both mats in front (harder to step backwards)  Harder – Don’t allow a “dead beat” when changing to other foot  Posture:  Easier -Cane for balance  Harder – Perform with eyes closed

19. Applying Domains of Challenge  Computer:  Easier or Harder -Increase or decrease tempo  Extremity  Easier –Place colored targets closer to center of mass  Posture:  Harder – Perform standing or on sitting on physioball  Cognition  Harder – Verbalize color of paper as patient taps

20. Applying Domains of Challenge  Computer:  Easier or Harder -Increase or decrease tempo  Extremity  Easier –Place numbers on table instead of wall  Harder – Place higher on wall so reaching overhead  Posture:  Harder – Patient stands farther away from targets so greater weight shift is required  Cognition  Harder – Verbalize number that is being tapped  Environment  Harder – Perform in busy hallway or gym

21. Exercise Intensity & Frequency  Repetition and frequent trainings are necessary for progress  Recommend IM training 3-4 times per week, minimum of 1200 “hits” per session. Typically takes about 30 minutes, including rest breaks IM Reports – General Reports – Total Minutes/Repetitions  If patient is unable to participate with this intensity, gains will take longer

22. Sample Exercise Program  Link provided to a sample plan on the Materials Page  Sample treatment plan module 4.pdf Sample treatment plan module 4.pdf  Link provided to a sample plan on the Materials Page  Sample treatment plan module 4.pdf Sample treatment plan module 4.pdf

24. Reassessment to determine progress  Administer Short Form Test weekly  Administer Long Form Assessment every 2-3 weeks  Administer other standardized tests as appropriate  Is the patient demonstrating improvement on assessments? Report less falls? Report more confidence with balance? Can take 6-8 sessions to note changes in balance, motor planning, timing, and sequencing.  What is the patients tolerance for therapy? Do you need to increase the exercise challenge?  Administer Short Form Test weekly  Administer Long Form Assessment every 2-3 weeks  Administer other standardized tests as appropriate  Is the patient demonstrating improvement on assessments? Report less falls? Report more confidence with balance? Can take 6-8 sessions to note changes in balance, motor planning, timing, and sequencing.  What is the patients tolerance for therapy? Do you need to increase the exercise challenge?

25. Homework Complete worksheet provided on materials page to design exercise plan at appropriate challenge level for your patient. Use the same patient as in module #2 and #3. worksheet module 4.pdf Complete worksheet provided on materials page to design exercise plan at appropriate challenge level for your patient. Use the same patient as in module #2 and #3. worksheet module 4.pdf

29. Post-test  Complete post-test to receive link for Module # 5 of 6

30. Materials Page  This video  PowerPoint  Sample treatment plan  Module 4 worksheet  Post test  www.interactivemetronome.com/index.php/fall-risk-coaching www.interactivemetronome.com/index.php/fall-risk-coaching  This video  PowerPoint  Sample treatment plan  Module 4 worksheet  Post test  www.interactivemetronome.com/index.php/fall-risk-coaching www.interactivemetronome.com/index.php/fall-risk-coaching

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