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14 déc. 2013 (il y a 3 années et 9 mois)

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Fall Risk Reduction Program

Patient Assessment

Module
#2

of 6

Shelley Thomas, MPT, MBA

Dara Coburn, M.S.,
CCC
-
SLP

AGENDA


Patient assessment


Choosing
the most appropriate
assessment protocol


Choosing
the top systems of balance
impacting falls


Q
&
A

Patient Selection


Patient and family goals and

expectations


History of falling? Fear of falling?


Weight bearing status


Able to weight bear as tolerated? Or partial weight
bearing?


Cognitive and communicative status


Attend to task for at least
60

seconds

to 2 minutes
?


Able to communicate basic wants and needs?


Follow simple directions?


Inpatient vs. outpatient


Intensity of treatment

Patient Selection


Discharge Disposition


Home with help
?


Home alone?


Ongoing treatment?


Concomitant diagnosis


Tolerance to exercise?


Medications?


Vision and Hearing Status


Does the patient have adaptive equipment?


Is the equipment available for their use?

Patient Selection, cont.

Candidates for this program should have goals that
include ambulation and/or lower extremity weight bearing
transfers


Standing pivot/squat pivot transfers


Modified depression transfers


Ambulation with or without a device

Patients that are dependent with transfers or unable to
walk
or have severe to profound cognitive and/or
communication deficits


May require therapy for other reasons, but focus is less likely
on decreasing falls. Often focus is on caregiver training,
wheelchair mobility,
compensatory strategies
etc.

Long Term Goals

Functional Limitation

Sample Goal

Fall or loss of balance at home in past month = 6

Patient will only experience two falls or loss of
balance in home per month to decrease risk of
injurywithin 8 weeks.

Falls or loss of balance in community, on uneven
surfaces, in last month = 8

Patient will only experience three falls or loss of
balance in the community per month to decrease
risk of injurywithin 8 weeks.

Unable to safely ascend or descend stairs without
physical assistance due to fear of falling

Patient will ascend and descend 12 steps with a
hand rail independently within 6 weeks.

Increasing risk of falling when reaching for objects
secondary to poor balance reactions

Patient will safely be able to reach for objects
outside of base of support and demonstrate
appropriate balance reactions (ankle, hip, stepping
strategies) to prevent loss of balance within 6
weeks.

Long Term Goals

Functional Limitation

Sample Goal

Unable to transfer on/off toilet or chair without use
of a walker

Patient will transfer independently on/off chair or
toilet within 6 weeks.

Demonstrates increased fall risk while cooking
because difficulty with balance, carrying objects, and
focusing on cooking task

Patient will demonstrate improved dual
-
tasking
ability by being able to prepare a basic meal without
loss of balance within 4 weeks.

Unable to maintain attention and focus to safely
complete ADL’s

Patient will demonstrate sustained & accurate visual
attention and processing in order to complete a task
with 70% accuracy over 3 minutes.

Unable

to self
-
regulate

Patient will demonstrate sustained attention to task,
self
-
monitoring, & self
-
correction during a cognitive
-
motor task with fewer than 3 errors in a 3 minute
time period.

Unable to follow moderately complex directions

Patient will demonstrate improved receptive
language and auditory comprehension skills by
following a 2 step cognitive/motor task with 50%
accuracy and moderate cues.

Short Term Goals


Patient will perform both toes for 2

minutes with while holding onto walker

for balance and achieve <200
ms

task

average with difficulty level set at 300,

tempo set at 54
bpm
, and guide sounds on.


Patient will attend to task during a synchronized
cognitive/motor activity for 2 minutes with moderate
cues and/or redirection, achieving a temporal
processing score within 150
ms

of the reference beat in
order to persist in daily activities and complete them
without constant prompting

Documentation

Documentation
should

include:


IM

task to be completed


Task average to be achieved


IM settings (i.e. tempo, if guide sounds are
on/off, difficulty level, etc.)


Assistance to be provided (i.e. verbal cues,
hands on cues, modeling, etc.)


Relationship to functional outcome

Narrative Note Example

Soap Note Example:


S


Patient seen for skilled speech therapy. He was alert and
oriented. He participated well in treatment and had no complaints
of pain.


O


Patient will follow a 2
-
step direction


A


Performed a cognitive/motor task direction in the presence of
auditory cues and repetitive task practice with hand over hand
assistance. Required more assistance from clinician as complexity
of auditory cue and feedback was added. Has difficulty in
distraction. Required moderate assistance to persist.


P


Increase complexity of feedback, reduce amount of clinical
assistance require. Alternate between two different sets of
directions as tolerated.


Slide
10

Determining Patient Baseline


Use both IM assessments


and standardized


evaluation tools to
determine baseline prior

to starting Fall Risk

Reduction Program

IM Assessments


Short Form Test (SFT)


Patient performs two 1
-
minutes task


One without guide sounds, the other with guide sounds


Provides baseline task average for ability to pair auditory information
with motor sequencing task


Long Form Assessment (LFA)


14 tasks, evaluates coordination and sequencing with different motor
tasks


Takes approximately 20
-
25 minutes to administer


Modify to meet the patient’s current level


Document any modifications provided


Should administer one of these assessments when evaluating
patient

Standardized Assessments


Multitude of standardized

assessments that can be

used to assess fall risk,

ability to perform activities

of daily living, cognitive status


Important to assess dual
-
tasking impact on
balance


It's good a person can walk. But can they walk
and talk? Walk and carry a glass of water? Be
safe when distracted?

Motor Assessments


Motor/Balance

Assessment:


TUG


Tinetti

Scale


Functional Reach


Dynamic Gait Index


6
-
Minute Walk Test

Cognitive Assessments


RIPA


SCATBI


Test of Variables of Attention


Stroop

Affect


Trail Making


Delis
-
Kaplan Executive Functioning Scale (D
-
KEFS)


Mesulam

and
Weintraub

Cancellation Test (MWCT)



Mini Mental State Examination (MMSE)


Wisconsin Card Sorting Test (WCST)


Woodcock
-

Johnson, 3rd Edition (WCJ
-
III)

Confidence Assessments


Activities
-
Specific Balance Confidence (ABC)
Scale


Modified Falls Efficacy Scale



Including a confidence assessment


helps determine if the patient has
less concerns about falling and

is perceiving improvements in

physical abilities.

Other Useful Tools and Assessments


Functional Assessment Tool

(Developed by Amy Vega)


Stroke Impact Scale


Canadian Occupational
Performance Measure

Timed Up & Go Modification

to Assess Dual Tasking


Can modify the TUG to incorporate a
cognitive and physical task


Administer TUG under following
conditions:


Traditional conditions


While carrying a glass of water


While counting backwards from 100 in serial
7's

Normative Values

TUG Condition

High Risk for Falling:

TUG Alone

> 13.5 seconds

TUG Manual (carry full glass of
water)

> 14.5 seconds

TUG Cognitive (count backwards)

> 15 seconds

Shumway
-
Cook, A., Brauer, S., & Woollacott, M. (2000, September). Predicting the probability for falls
in community
-
dwelling older adults using the timed up & go test. Physical Therapy , 80(9), 896
-
903.

Create a Dual Task Condition

with Short Form Test

Compare traditional SFT score with a dual
-
task
condition (document how you create dual
-
task
so it can be replicated). Perform SFT while:


Counting aloud


Marching in place


Transfering sit to/from stand


Walking (use in
-
motion triggers)


Naming objects

Summary of Patient

Selection & Assessment

1.
Patient should have goals that include
ambulation and/or transfers (that involve lower
extremity weight bearing)

2.
Use standardized assessment tools to
evaluation motor and cognitive performance

3.
Use IM assessments to get a baseline on ability
to pair auditory information with motor
sequencing.

4.
Assess performance under dual
-
task conditions

"Homework"


Complete following
worksheet to select
and assess your patient

Post
-
test


Complete post
-
test to receive link for
Module # 3 of 6

Materials Page


This video


PowerPoint


Patient Selection Worksheet



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