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Detection and Assessment: Theory - Finding fallers…in different settings: - Pre-exercise assessment - Health, Function and Motivation - Ongoing assessment - Triggers for referral to medical setting - Triggers for referral between exercise settings Specialist PSI Exercise Module Targeting Intervention Identify high risk from a general population Identify what more in depth assessment is required Identify modifiable risk factors for each individual Target Intervention Specialist PSI Exercise Module NICE Falls CG: “Safety net” service model Specialist PSI Exercise Module NICE Falls CG: specialist integrated service model Specialist PSI Exercise Module What tool or test ? It needs to be: Reliable same result in same person over short intervals of time Consistent same result whoever assesses Valid for the age and functional capacity of the individual Plus functional and understandable to the older person Specialist PSI Exercise Module The role of pre-exercise assessment • Assessment – is the cornerstone of rehabilitation – identifies health status (safety and warning signs) – identifies areas of limitation (pre-exercise) – influences subsequent treatment/intervention (tailoring) – gauges efficacy of treatment (ongoing) Specialist PSI Exercise Module Pre-exercise Assessment • Assessment should be: – what they can do and build upon …..NOT. …. what they cannot do – an education tool (fitness vs health symptoms) – relevant (age, medical condition and functional capacity of the participant) Specialist PSI Exercise Module TRIGGERS Referral back to Rehab Exercise Setting • Onto therapy setting (or stay within chair-based setting) – – – – – cannot stand for more than 30 seconds without excessive sway cannot transfer weight from one leg to another without concern cannot take a step backwards unassisted chronic or acute pain on walking marked deformities, severe asymmetry, marked weakness Functional Grid • ticks mainly 6’s Specialist PSI Exercise Module Ongoing Assessment • ? Every 3 / 6 / 9 months or if participants health or functional condition deteriorates • Essential for – updating health or functional status information – assessing effectiveness of programming – comparing goals with actual gains – improving motivation • Continually assess – environment and safety – ‘appearance’ of participants – correct intensity (Borg) Specialist PSI Exercise Module TRIGGERS Ongoing assessment - 1 • Sudden onset of symptoms of illness – Dizziness, inner ear infections, excessive tiredness, weight loss, loss of appetite or shortness of breath, anxiety, unidentified or uncontrolled pain • Worsening of existing medical condition – Frequency of transient ischaemic attacks increases, swelling of an OA knee following the session or a longer than usual walk • Onset of dizziness with current or new medications or concerns about whether correct pills are being taken at the correct time or dose • Sudden onset of pain in joints – Osteoarthritis of the knee, swollen joints, limping Specialist PSI Exercise Module TRIGGERS Ongoing assessment - 2 • Deterioration of functional capacity or balance – Now needs walking aid, progressive difficulty with walking on the flat, fatigues more quickly, transfers becoming difficult • Increase in frequency of falls or increase in injury due to falls – Starts to fall at home in repeat areas of the house or doing certain tasks, can no longer rise from the floor, injuries not healing properly, arrives with a black eye and has not been to see the GP after the last fall yet • Distinct changes in vision – Depth perception, missing steps, light-headedness on walking downstairs with bifocals • Distinct changes in hearing – Wax removal, inner ear infection Specialist PSI Exercise Module The value of assessment • You get to know your participants • Good time to discuss exercise history, likes, dislikes and perceptions of exercise and of falling • You’re safe and so are they • You know where to start and where to adapt • You know if you are getting it right • Funder’s know you are getting it right • Participants feel informed Specialist PSI Exercise Module Case Study Guidelines • Find a person at risk of falls or with a falls history that would be able to join a PSI led class • Perform functional assessments and do the health / QoL / fear of falling questionnaires with them • Write up – 1500 words • Include tailor / adapt the FaME phases of training for that individual • Present the written case study on Day 6/7 • See Case Study Guidelines in your pack Specialist PSI Exercise Module Practical / Case Study Guidelines • Pre-exercise Assessment – – – – – – – – Readiness to exercise Health Falls Risk (FRAT) Fracture Risk (Black) Fear of Falling (FES-I ) Confidence in Maintaining Balance (ConFBal) Health outcome (EQ-5D) Functional Assessments - GRID Specialist PSI Exercise Module Selection Criteria -Is your participant at risk of falls? Each individual should have one or more of the following: • Fear of falling • Feeling unstable (balance problems) • History of falls (injury or not) • Low bone density (and/or family history of osteoporotic fracture) Specialist PSI Exercise Module Readiness to Exercise • Stage of Health Behaviour Change – – – – – – Considering Preparing Currently Active <6 Months Regularly Active >6 Months Relapse Unknown • Gauge from a conversation with them about exercise history and current participation Specialist PSI Exercise Module Health Assessment Referred or self-referred • Health status must be checked with / acknowledged by participants GP • Complete a health questionnaire with them that will identify their medical conditions and medications • Use to ensure your know if someone has any conditions which are contraindicated and need specific feedback from GP before they can continue in the class • A health questionnaire is in your case study pack but when you qualify you may use one that has been developed by your service. Specialist PSI Exercise Module Contraindications to the ‘Prehab’ Class People with the following: • Uncontrolled angina • Uncontrolled resting BP > 180/100 mmHg Significant drop in BP during exercise Uncontrolled tachycardia > 100 bpm Unstable or acute heart failure Uncontrolled acute systemic illness • • • • • • • • • Uncontrolled visual or vestibular problems Unable to maintain seated upright position Recent injurious fall without attention Impaired cognition Place others and themselves at risk should not take part until their GP advises that their condition permits safe participation Specialist PSI Exercise Module History of Fall • Number in last 6 months • Last one – – – – – – – – Location Time Doing what? Reason? Loss of consciousness? Or dizziness prior? Any injury? Could they get up again? Did they see GP or go to Hospital? Specialist PSI Exercise Module FRAT – Falls Risk Assessment Tool Multi - professional guidance for use by the primary health care team, hospital staff, and social care workers Is there a history of any fall in the previous year? How assessed? Ask the person. Is the patient / client on four or more medications per day? How assessed? Identify number of prescribed medications. Does the patient / client have a diagnosis of stroke or Parkinson's Disease? How assessed? Ask the person. Does the patient / client report any problems with their balance? How assessed? Ask the person. Is the patient/client unable to rise from a chair of knee height? How assessed? Ask the person to stand up from a chair of knee height without using their arms. Specialist PSI Exercise Module Risk of Fracture Tool • Black 2001 – High risk Score 7-10 – Moderate risk Score 5-6 – To use in your case study Specialist PSI Exercise Module Fear of Falling Scale – FES-I • Long Version – 16 Qs – Yardley et al. 2006 • Short Version – 7 Qs – Kempen et al. 2008 – To be used for your case study – Scoring • 7 (no concern about falling) to • 28 (severe concern about falling). ProFaNE recommended Specialist PSI Exercise Module Confidence in Maintaining Balance • Simpson et al. 2004 • 10 Qs • Scoring – 10 confident – 30 unconfident • Use for your case study Specialist PSI Exercise Module EQ-5D – heath outcome measure • Page 1 So this would score as: 1,2,3,4,5 Specialist PSI Exercise Module EQ-5D • Page 2 Specialist PSI Exercise Module Functional assessment No Limitation Seated shoulder external rotation flexibility Can reach over their shoulder to between their shoulder blades Denote L and R arm in box(es) 1 Seated shoulder internal rotation flexibility Can reach to behind the back to touch their shoulder blades Denote L and R arm in box(es) 1 Seated hamstring flexibility Able to reach to midcalf of the extended leg Denote L and R arm in box(es) 1 180 degree turn Able to turn safely in 4 steps or less Number of steps: ______ 1 Functional Reach Reaches greater than 35 cm Use of walking aid? Cm:____ 1 Timed Up and Go Use of walking aid? Time (seconds):_____ Able to rise from the chair easily, walk unaided, turn without dizziness or stumbling. Faster than 8 seconds 1 Severe Limitation Can reach to the back of the neck 2 Can reach to behind the back to touch just below the shoulder blades 2 Able to reach just past knee of the extended leg 2 Able to turn safely in 6 steps or less 2 Reaches between 25 and 34 cm 2 Able to rise from the chair without arms, walk unaided, turn without stumbling. Between 9 and 15 seconds 2 Can reach behind the head to level of ears 3 L Can reach behind to mid-back level 3 L Able to reach to knee of the extended leg 3 Able to turn safely in 8 steps or less 3 Reaches between 16 and 24 cm 3 Difficulty on rising from chair, walks aided or unaided but takes between 16 and 24 seconds 3 Can reach the top of their head 4 R Can reach behind to waist level 4 R Able to reach to mid thigh of the extended leg 4 Needs close supervision and verbal cueing for safety. Takes 9-12 steps 4 Reaches between 10 and 15 cm 4 Difficulty on rising from chair, walks aided or unaided but takes between 25 and 40 seconds 4 Can reach above shoulder level but not touch the top of their head Unable Unable to reach above shoulder level without pain or movement limitation 5 6 Can reach behind to buttock level Unable to reach behind their back, pain or movement limitation 5 6 Able to reach to knee but unable to complete with correct technique 5 LR Needs assistance from one person or furniture to turn 5 Reaches less than 10 cm 5 Difficulty on rising from chair, needs walking aid, unconfident or dizzy on turning or takes over 40 seconds 5 Unable to reach forward because of pain, deformity or fear of falling 6 Needs assistance from two people to turn 6 Unable or afraid to reach forward 6 Unable to rise from the chair, walk or turn without help 6 Specialist PSI Exercise Module FLOW DIAGRAM FOR PROSPECTIVE PARTICIPANTS IN EXERCISE SESSIONS TO IMPROVE POSTURAL STABILITY AND REDUCE FALLS AND INJURIES Referrer Selection Criteria Functional Assessment Grid Exercise Groups Mostly ticks SELF – REFERRED 1 2 DYNAMIC ‘PREHAB’ PSI 3 4 GP – PRIMARY CARE Those meeting inclusion criteria and having no exclusion criteria 5 6 PHYSIOTHERAPY REHABILITATION SETTING CHAIR – BASED (maybe PSI led or chair adaptations) P R O G E S S W I T H T I M E ‘REHAB’ – THERAPY (one to one or small group) Specialist PSI Exercise Module Final thoughts on case study • You need to tailor the phases of the FaME programme to your participants abilities – – – – Any limitations (adaptations) Any confidence issues (buddying) Are they particularly good at anything (so can progress faster) Asymmetry (homework) • In your judgement would they progress through any of the phases faster/slower? • Consider the main points of this individual you would want a cover teacher to know? – Medications – Limitations Specialist PSI Exercise Module