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Using a Multidisciplinary Approach to Determine Impairments in Movement and Mobility Dr. Cecelia Griffith, PT, DPT [email protected] What is the Multidisciplinary Team? Taber's Cyclopedic Medical Dictionary, 20th Edition “Relating to multiple fields of study involved in the care of patients. The term suggests that the various disciplines are working in collaboration, but in a parallel mode of interaction. Each distinctive discipline is accountable and responsible for its tasks and functions regarding patient care.” Importance of Multidisciplinary Approach to Geriatric Care Patient-centered Coordinated care: the right hand knows what the left hand is doing Holistic Physiological Functional Emotional Spiritual Role of the Multidisciplinary Team in Assessment and Treatment of Mobility and Balance Bowel & Bladder Neurological Musculoskeletal Vision Cognitive * * * * * * * * Discipline H&P Organ systems Physician * * Nursing * * * * Occupational Therapy * * * * * * * * Physical Therapy * * * * * * * Speech/ Language Pathologist * * * Psychologist * Ophthalmologi st * * * * Communication * Selfcare Education * * * Understanding Balance Multi-system Function Impacts all levels of mobility and function Every patient is a balance patient Dynamic Equilibrium Sensory Organization Motor Coordination Determination of Body Position Choice of Body Movement Compare, Select & Combine Senses Select & Adjust Muscle Contractile Patterns Visual System Vestibular System SomatoSensation Environmental Interaction Courtesy of Neurocom International Ankle Muscles Thigh Muscles Trunk Muscles Generation of Body Movement The Need for Balance and Fall Prevention Programs and Assessment. 2029 2003: 1.8 million older adults injured from falls 13,700 died of fall injuries Cost of falls ~ $43.8 billion by 2020 Older population increasing faster than total population Total population increasing 1.2% per year 65+ increasing 2.0% per year 75+ increasing 2.7% per year Demographics, Cont. Falls are leading cause of injury deaths Women are 67% more likely to fall Men are 49% more likely to die from falls Exercise decreases fall risk Effects of Aging on Balance Woollacott, MH and Shumway-Cook, A; Changes in posture control across the life span--a systems approach.; Physical Therapy, 1990 Dec;70(12):799-807. Declining Vision Sensory-neural Hearing Loss Declining somatosensory input (proprioception) Ankle dorsiflexor weakness Temporal organization of postural muscle responses changes Assessment of Balance Test Purpose Timed Up and Screening Go (TUG) Discipline(s) Patient Population All Geriatric MEOW Evaluation and Physician Diagnosis Geriatric Berg Balance Scale Objective evaluation PT, OT Frail elderly, neurologically impaired, low to mid-functioning adults Vision/VOR Objective evaluation MD/DO, PT, OT All Assessment of Balance, Cont. Test Purpose Discipline(s) Patient Population Dynamic Gait Objective Index (DGI) evaluation PT, OT All, medium to higher functioning adults Functional Gait Assessment (FGA) Objective evaluation PT Adults with vestibular impairment; has a format that combines with DGI Tinneti (POMA) screening MD/DO, PT, OT Frail elderly, low to midfunctioning adults Multiple Task Test (MTT) Objective evaluation PT, OT Parkinson’s Disease “MEOW” Nnodim, JO, Alexander, MB, Assessing falls in older adults: a comprehensive fall evaluation to reduce fall risk in older adults; Geriatrics. 2005 Oct;60(10):24-8 M E 0 Environmental Eyes Ethanol Orthostatic hypotension OUCH! (pain) Weakness in the lower extremities Multifactorial Medical (Acute) Medical (chronic) Medicines Mental Maladaptive assistive devices Multifocal lens W M Multifactorial, i.e., multi-system problem Medical (Acute): rule out acute etiologies Medical (chronic): evaluate for exacerbation of chronic conditions Medicines: at risk if on 3 or more medications, especially if for blood pressure or depression Mental: evaluate for depression and cognitive impairments Maladaptive assistive devices: are they using the appropriate device and is fit properly to them? Multifocal lens: evaluate for visual impairments and effects on balance of bifocals or trifocals E Environmental: Home safety Eyes (and ears) Throw rugs Night lights Clutter Trip hazards stairs Oculomotor exam Nystagmus DVA VOR Ethanol O Orthostatic hypotension Office testing Tilt-table test OUCH! (pain) Pain medications Limiting activity due to pain W Weakness in Lower Extremities Manual Muscle Testing Effect of Statin Drugs Search Pub Med: “myopathy AND statins” Rhabdomyolysis and Type 2 Muscle atrophy “Sit to Stand Test” “Stair Test” Berg Balance Scale “Gold Standard” developed in 1988 by K. Berg at McGill University and published in 1992. 14 items, scored on 0-5 scale 0-20 = High risk of falling 21-40 = Moderate risk of falling 41-56 = Low risk of falling Berg et al; Clinical and Laboratory Measures of Postural Balance in an Elderly Population; Archives of Physical Medicine and Rehabilitation, 1992 Nov;73(11):1073-80 Berg Balance Scale, Cont. Below 20: possible need for wheelchair assessment. 20-35: Generally indicates need for a walker 35-45: Generally indicates need for a cane Over 45, Generally safe without an adaptive device in most settings Quad cane vs. Single point cane TUG Use as a screening measure to determine need for further assessment (Berg or other measure). Place a tape/line 3 meters ( 10 feet) from the front of a stable chair with arms. Have the patient sit in the chair. Time the patient from the time you say “go” until they return to sitting in the chair. Stop timing when the patient’s buttocks hit the chair bottom. The chair should be firm with arms to push from if necessary. Instruct the Patient to stand when you say “go” walk forward at their normal pace to the mark, turn and walk back to the chair and be seated. Let them know they are being timed. Scoring: (3) < 11.5 seconds without evidence of imbalance. (2) > 11.5 seconds or has evidence of imbalance (1) > 11.5 seconds with (and) evidence of imbalance (0) Unable to perform without assistance Additional Tests to Consider Dynamic Gait Index Tinetti Future Development Functional Gait Assessment Multiple Tasks Test Tests specific to particular patient populations Questions? Bibliography Berg et al (1992). Clinical and laboratory measures of postural balance in an elderly population. Archives of Physical Medicine and Rehabilitation, 73(11):1073-80. Nnodim, JO. Alexander, MB. (2005) Assessing falls in older adults: a comprehensive fall evaluation to reduce fall risk in older adults. Geriatrics,60(10):24-8 Woollacott, MH. Shumway-Cook, A. (1990) Changes in posture control across the life span--a systems approach. Physical Therapy, 70(12):799-807. Woollacott, M. Inglin, B. Manchester, D. (1988) Response preparation and postural control. Neuromuscular changes in the older adult. Annals of the New York Academy of Sciences, 515:42-53. Shumway-Cook, A. Brauer, S. Woollacott, M. (2000) Predicting the probability for falls in community-dwelling older adults using the Timed Up & Go Test. Physical Therapy, 80(9):896-903. Bibliography Southard, V. Dave, M. Davis, MG. Blanco, J. Hofferber, A. (2005) The Multiple Tasks Test as a predictor of falls in older adults. Gait and Posture, 22: 351-55. Boulgarides, LK. McGinty, SM. Willett, JA. Barnes, CW. (2003) Use of Clinical and Impairment-Based Tests to Predict Falls by Community-Dwelling Older Adults. Physical Therapy, 83: 328-39. Steffen, TM. Hacker, TA. Mollinger, L. (2002) Age- and Gender-Related Test Performance in Community-Dwelling Elderly People: Six-Minute Walk Test, Berg Balance Scale, Timed Up and Go Test, and Gait Speeds. Physical Therapy, 82: 128-37. Lajoie, Y. Girard, A. Guay, M. (2002) Comparison of the reaction time, the Berg Scale and the ABC in non-fallers and fallers. Archives of Gerontology and Geriatrics, 35: 215-25. Whitney, S. Wrisley, D. Furman, J. (2003) Concurrent validity of the Berg Balance Scale and the Dynamic Gait Index in people with vestibular dysfunction. Physiotherapy Research International, 8: 178-86. Bibliography Lajoie, Y. Gallagher, SP. (2004) Predicting falls within the elderly community: comparison of postural sway, reaction time, the Berg balance scale and the Activities-specific Balance Confidence (ABC) scale for comparing fallers and non-fallers. Archives of Gerontology and Geriatrics, 38: 11-26. Hatch, J. Gill-Body, KM. Portney, LG. (2003) Determinants of Balance Confidence in Community-Dwelling Elderly People. Physical Therapy, 83: 107279. Whitehead, C. Miller, M. Crotty, M. (2003) Falls in community-dwelling older persons following hip fracture: impact on self-efficacy, balance and handicap. Clinical Rehabilitation,17: 899-906. Bloem, BR. Valkenburg, VV. Slabbekoorn, M. Willemsen, MD. (2001) The Multiple Tasks Tests Development and normal strategies. Gait and Posture, 14: 191-202.