Unit 4A - TBI

Bruise & Traumatic Brain Injury (TBI) Classification

  • Open (Penetrating) TBI:
    • Wounds caused by gunshots, knives, or sharp objects.
    • High risk of infection.
    • Often involves skull fracture or displacement.
  • Closed (Intracranial) TBI:
    • Impact to the head without skull fracture or displacement.
    • Includes:
      • Concussion:
        • Most common.
        • Graded 1, 2, or 3.
      • Contusion:
        • Bruising on the surface of the brain with small vessel hemorrhage.
        • Coup Injury: Bruising at the site of impact.
        • Contrecoup Injury: Bruising on the opposite side of the brain from the impact, due to the brain hitting the skull on the rebound.
      • Hematomas:
        • Epidural Hematoma: Blood fills the space between the dura mater and the skull.
        • Subdural Hematoma: Blood fills the space beneath the dura mater.

Brain Structures

  • Protective Structures:
    • Dura mater
    • Arachnoid mater
    • Pia mater
  • Spinal Cord Structure
    • Gray Matter:
      • Dorsal horn
      • Ventral horn
      • Lateral horn
    • White Matter:
      • Dorsal column
      • Lateral column
      • Anterior column
    • Meninges:
      • Spinal dura mater
      • Spinal arachnoid
      • Spinal pia mater

Other Conditions Associated with TBI

  • Anoxic brain injury
  • Meningitis
  • Seizures
  • Epilepsy
    • Disease characterized by recurrent seizures
    • Classification:
      • Generalized:
        • Tonic-Clonic
        • Tonic
        • Clonic
        • Atonic
        • Absence
        • Myoclonic
      • Focal

Scales to Measure Recovery Stages

  • Glasgow Coma Scale (GCS)
    • Score ranges from 3 to 15 (higher is better).
    • Measures the level of consciousness and severity of injury.
    • Mild: 13-15
    • Moderate: 9-12
    • Severe: 3-8
    • Components:
      • Eye Opening (1-4)
      • Motor Response (1-6)
      • Verbal Response (1-5)
      • The overall score is the sum of the eye opening, motor response, and verbal response scores.
  • Rancho Los Amigos Level of Cognitive Functioning Scale (LOCF)
    • Measures the sequence of cognitive and behavioral recovery.
    • Ranges from Level I to VIII (higher is better).
    • Levels:
      • Level I - No Response: Total Assistance. Complete absence of observable change in behavior when presented with stimuli.
      • Level II - Generalized Response: Total Assistance. Demonstrates generalized reflex response to painful stimuli; inconsistent response to auditory stimuli.
      • Level III - Localized Response: Total Assistance. Responds inconsistently to simple commands; may respond to some persons but not others.
      • Level IV - Confused/Agitated: Maximal Assistance. Alert and in a heightened state of activity; may remove restraints or tubes; absent short-term memory; aggressive behavior; incoherent verbalizations.
      • Level V - Confused, Inappropriate Non-Agitated: Maximal Assistance. Not oriented to person, place, or time; frequent brief periods of non-purposeful attention; severely impaired recent memory; may wander randomly.
      • Level VI - Confused, Appropriate: Moderate Assistance. Inconsistently oriented; able to attend to familiar tasks for 30 minutes with redirection; emerging awareness of self, family, and basic needs; unaware of impairments and safety risks.
      • Level VII - Automatic, Appropriate: Minimal Assistance for Daily Living Skills. Consistently oriented to person and place in familiar environments; able to attend to familiar tasks for 30 minutes with minimal assistance; minimal supervision for new learning; unrealistic planning for the future.
      • Level VIII - Purposeful, Appropriate: Stand-By Assistance. Consistently oriented to person, place, and time; independently attends to and completes familiar tasks for 1 hour in distracting environments; aware of impairments and disabilities when they interfere with task completion.
  • Rappaport’s Disability Rating Scale (DRS)
    • Measures the level of disability according to function
    • Score ranges: 0 – 30, with lower scores indicating more normal function
  • Glasgow Outcome Scale (GOS)
    • Measures outcomes/where the patient ends up.
    • Score ranges: 8 categories from “dead” to “good recovery”
    • Used for research
  • Diagnostic Procedures
    • Electroencephalograms (EEG) and Evoked Potentials (EP): Measures CNS activity. Easy to obtain, noninvasive, inexpensive.
    • Computer Tomography (CT): Detects hematomas and atrophy but not lesions as well as MRI.
    • Magnetic Resonance Imaging (MRI): More sensitive to post-traumatic lesions.
    • Cerebral Blood Flow Mapping: Clarifies the relationship between physiology and behavior. Looks at cerebral metabolism.

Direct Impairments Associated with TBI

  • Variety and complexity of impairments are what makes TBI interesting and challenging.
  • Listed on page 861 of O&S Box 19.1 and M&K pages 428-429
    • Decreased Level of Consciousness
      • Coma: GCS of 8 or less; does not obey commands, speak, or open eyes.
      • Persistent Vegetative State (PVS): Opens eyes, but no speech or purposeful behavior.
      • Post-Traumatic Amnesia (PTA): Cannot remember recent past events, i.e., no carryover from day to day.
    • Cognitive Deficits
      • Most patients are left with residual cognitive deficits; never 100% normal.
      • Decreased attention span
      • Decreased motor planning may be subtle
      • Disorders of learning and memory
      • Disorders of complex information processing need long term ST and OT (Speech Therapy and Occupational Therapy)
    • Motor Deficits
      • General deconditioning: General weakness, loss of flexibility, decreased nutrition.
      • Hemiparesis: May present similarly to CVA, depending on the type of injury.
      • Bilateral hemiparesis: Deficits on one side may be different from deficits on the other
      • Balance deficits: Very common; must do high level balance activities
      • Ataxia and incoordination: Gait disturbance and lack of smooth execution of movement.
    • Sensory Deficits
      • See Unit II-A Neuro Assessments
    • Communication Deficits
      • Receptive and expressive aphasia similar to CVA
    • Behavioral Deficits
      • Socially inappropriate behaviors are the most challenging part of TBI!!!
    • Associated Deficits
      • Fractures (Fxs), peripheral nerve injuries (PNI), spinal cord injuries (SCI), internal injuries.
      • See O & S Box 19.2, p. 863 and pp. 862-863, M&K pp. 426 - 427

Management in Acute Phase

  • Medical Management and PT Interventions

  • Listed on M&K pp. 429 432 and O&S pp. 866 - 870

    • Medical Management

      • Severity of injury: Often difficult to assess initially/get baseline
      • EEG - may be in PVS
      • Preservation of life: Adequate airway, oxygen.
      • Stabilizing BP, keep circulation intact.
      • Prevention of further damage: Hypothermia cooling to prevent edema
      • Monitor ICP intracranial pressure with catheter or transducer placed in the brain
      • Interdisciplinary team approach O&S pp. 864 - 866
      • Not just PT. Includes patient, family, MD, SLP, OT, Rehab Nurse, Case Manager, MSW, Psychologist, etc.

    • PT Goals in Acute Phase

      • O&S Box 19.4 p. 868
      • full body extension lesion in the brainstem
      • UE ü and LE ⁄ lesion at or above upper brainstem decorticate rigidity vs. decerebrate rigidity see O&S p. 169 for an explanation of these terms
        1. To prevent contractures.
        2. To prevent skin breakdown.
        3. To prevent respiratory problems.
        4. To maintain/increase sensory & cognitive awareness.
      • Reflexive Postures – Brainstem Level Reflexes
        • ATNR: Asymmetrical Tonic Neck Reflex
        • STNR-EXT: Symmetrical Tonic Neck Reflex-Extension
        • TLR: Tonic Labyrinthine Reflex
        • STNR-FLEX: Symmetrical Tonic Neck Reflex-Flexion
        • decorticate rigidity
        • decerebrate rigidity

    • PT Interventions in Acute Phase

      1. Positioning: Reflex Inhibiting Postures (RIPs) M&K p. 430 Interven 12-1 and 12-2
      2. Splints/casts: Multi-podus boot Serial casting O&S pp. 867 - 869
      3. Tilt table: To increase weight-bearing. To decrease orthostatic hypotension.
      4. PROM: To prevent contractures. For sensory stimulation. Explain what you are doing during ROM.
      5. Chest PT: Postural drainage, percussion, and vibration To keep lungs clear. No head down positions.
      6. Sensory Stimulation: Auditory, visual, olfactory, tactile, talk to patient, keep radio playing.
      7. Cognitive Functioning: Plan interventions to improve arousal as patient becomes more alert.
      8. Patient/Caregiver Training:
        • Positioning, ROM, suctioning

Assessing Arousal, Attention, Orientation and Cognition

  • PHT 1130 Data Collection Skills Unit 1.04 ,O & S pp. 79 – 81
    • Arousal
      • A state of responsiveness of the human system to sensory stimulation
      • Described in terms of LOCs (Levels of Consciousness):
        • Alert
        • Lethargic
        • Obtunded
        • Stupor
        • Coma

Inpatient Rehabilitation Phase

  • Listed on M&K pp. 432 - 443 & O& S pp. 829 - 845
    • PT Interventions
      • Positioning Wheelchair Propulsion
      • ROM: Needs depend on resting posture, tone, reflexes. Side lying, prone, sitting M&K Intervens 12-1 and 12-2, p. 430; 12-3 p. 435
      • Encourage independent w/c propulsion in facility
      • Stretching: Especially hamstrings and heel cords. Incorporate stretching positions into Rxs. Serial casting O&S pp. 867 - 869
      • Improving Awareness
      • Family Education
      • Functional Mobility Training
        • Of self and environment. Use of “scripts” . Assist with orientation & awareness. Avoid overstimulation. Co-treat with OT/OTA. Inhibit abnormal tone. Facilitate normal movement.
        • Sitting Activities: May need assistance of two to co-treat. Patient maintains neutral spine/anterior pelvic tilt. Supine to sit: M&K Intervention 12-5, p. 439 helicopter maneuver Trunk flexion in sitting: M&K Intervention 12-6, p. 441
      • Sitting activities: M&K Intervention 12-7, p. 442
      • Transfers: M&K Intervention 12-8, p. 442
        • Sit-pivot transfer for those with low level of function and poor trunk control.
      • Standing Activities: M&K Intervention 12-9 and 12-10, p.443
        • Increases weight bearing and sensory input.
      • Physical Environment: Easily distracted and overstimulated. Smaller, quiet Rx areas, lots of structure and consistency. As LOCF improves: Decrease structure and Decrease consistency.

Cognitive and Behavioral Impairments

  • Mandatory reading - Martin & Kessler pp. 444 - 447

    • Common Impairments

      • Disorientation to place, time, situation: Use of a memory book with key information.
      • Attention Deficits: Simple commands: KISS principle (keep it short & simple). Use a variety of activities. As LOCF improves: Use stopwatch to encourage attention to task.
      • Memory Deficits: Often left with residual memory problems. Use memory book similar to a day planner.
      • Problem-Solving Deficits: Practice problem solving in safety issues.
      • Behavioral Deficits: Agitated, irritable, poor emotional control. Ignore inappropriate behaviors. Reward appropriate behaviors.
      • Aggressive Behaviors: Aggressive & combative. Crisis intervention skills staff trained to deal with acting out. Behavior management reinforce (+) behaviors. Be supportive encourage (+) behaviors. Redirect focus attention on something new/different.

    • Management Based on Cognitive Level

      • Organization of Rx is built around patient’s cognitive level.
      • Low-Level Management: LOCF I – III (O & S p. 827 Box 19.3)
        • I = No Response; II= Generalized Response; III= Localized Response
        • PT Evaluation: See O & S page 830, Box 19.5 needs to be repeated as pt. progresses
        • Interventions: ROM: PROM and stretching
        • Sensory stimulation
        • Positioning: RIPs see Management in Acute Phase above
      • Mid-Level Management: LOCF IV – VI Level IV O & S Table 19.5 p. 827
        • IV = Confused and Agitated need VERY structured and quiet environment
        • Patient is confused: Same PT/PTA, same time, same place
        • Expect no carry-over: Fixed daily routine
        • Show calm behavior: The more agitated the patient gets, the more calm you get
        • Short attention span: Short Rx sessions, gradually lengthen
        • Numerous activities: Pick tasks that are favorite/familiar
        • Offer options: 2 good choices: Do you want to do
        • Expect egocentricity: Self-centered behavior is normal at this stage
      • Level V & VI
        • V = Confused Inappropriate, VI = Confused Appropriate still confused, but not as agitated; will follow commands
        • Maintain structure: Change may confuse patient
        • Emphasize safety: May think they can do more/poor judgment
        • Keep instructions to a minimum: Speak slowly, short phrases, allow time for delay
        • Use physical props: To improve compliance: Swiss ball, timer eye-hand coordination “toys” .
      • Mid-Level Management: LOCF VII & VIII
        • Level VII & VIII, VII = Automatic Appropriate VIII = Purposeful Appropriate getting ready for D/C; wean them from structure
        • Carry-over rate still slow: Repetition still important/less critical
        • Involve patient in decision making: Patient should be aware of own strengths/weaknesses more problem solving
        • Integrate cognitive, physical, and emotional skills: So pt. can integrate into world as a functional person
        • Emphasize judgment, planning, and problem-solving: ADL skills, social skills, community skills
        • See Table 12-2 in M & K on p. 435 for Levels IX and X

Mild Traumatic Brain Injury (mTBI)

  • see O & S pp 840-845
    • Loss of consciousness
    • Loss of coordination
    • Headache that persists or worsens
    • Extreme Confusion
    • Dilation of one or both pupils
    • Seizures or convulsion
    • Spinal Fluid coming out of the ears or Nose
    • Numbness or weakness in the fingers and toes
    • Inability to awaken from sleep
    • Slurred speech

Principles of Experience-Dependent Plasticity

  • A summary of the principles and desciptions follows:
    • Principle Description
      • Use it or lose it Lack of activity of certain brain functions can lead to functional loss.
      • Use it and improve it Training a specific brain function can lead to improvement in that function.
      • Specificity The training experience must be specific to the expected change.
      • Repetition Active repetition is needed to induce change.
      • Intensity Training must be of a sufficient intensity to induce change.
      • Salience The stimulus used to produce a response must be appropriate.
      • Age Plasticity is more likely to occur in the young brain versus the older brain.
      • Time Timing of intervention may help or hinder recovery.
      • Transference Training on one task may positively affect another similar task.
      • Interference Plasticity in response to one experience can interfere with the acquisition of other behaviors.

Other Considerations

  • Coma
    • Unusual behavior, including combativeness, anxiety and agitation
  • Issues That Cross All Cognitive Levels
    • ROM: A never-ending battle due to abnormal tone
    • Mobility: Help pt. to be as independent as possible
    • Documentation: Relate Rx to LOCF
    • Goal setting and Outcome
    • Other areas of the brain can take over for the damaged areas depending on age of patient
    • May continue to learn 2 – 8 years later!!
  • Neuroplasticity O&S p. 403 and M&K Table 3-4 p. 59
    • Problem-solving is like a motor activity for the brain
    • The more you exercise your brain, the more synapses you grow

Treatment Planning In TBI

  • Consider pre-morbid personality & social environment

Behavioral Management

  • Most critical
  • Socially disabling condition due to:
    • Aggression
    • Low frustration level
    • Sexual disinhibition
    • Use: Lots of praise (+ reinforcement) Activities that will build success

Motor Learning and Motor Control

  • Facilitate:
    • Normal postural reflexes
    • Balance reactions
    • Proprioception
    • Impaired Balance

Lesson Objectives for Balance Training

  • Define key terms associated with the concept of balance and postural stability.
  • Identify the neural structures primarily responsible for the integration and processing of sensory information for balance control.
  • Describe which sensory systems provide information for balance control in both a static environment and a dynamic environment.
  • Recognize specific motor strategies typically used by healthy individuals to compensate for balance disturbances.
  • Differentiate and discuss evidence-based treatment activities to address various balance impairments and functional limitations.
  • Demonstrate the ability to progress balance activities in response to patient participation restrictions.
  • List appropriate considerations for treatment interventions and education to address fall risk associated with vision loss, sensory loss, age, and medications.
  • Recognize fall risk factors associated with age, medications, and environmental and health-related factors.

Falls Statistics

  • Nearly 1 million people visit ER as a result of a fall
  • 1/3 of 65+ year old adults fall at least one time/year
  • This will increase with age
  • The projected cost for fall injuries is over 3030 billion

Background and Concepts Balance Key Terms and Definitions

  • Center of mass (COM): The point at which the body is in perfect equilibrium. Located just anterior to S2 vertebrae.
  • Center of gravity (COG): The vertical projection of the COM to the ground
  • Momentum: Product of mass x velocity
  • Base of support (BOS): Perimeter of the contact areas between the body and its support surface
  • Limits of stability: Sway boundaries to maintain equilibrium without changing BOS
  • Ground reaction force: Newton’s law of reaction

Balance Control

  • Nervous system – visual, vestibular, and somatosensory; processing, integration, motor planning and execution
  • Musculoskeletal contributions – postural, flexibility, joint integrity, muscle performance, sensation
  • Contextual effects – how these 2 systems interact with the environment; open or closed; kind of surface; lighting; effects of gravity; familiarity with enviro; multi-tasking?

Balance Defined

  • State of physical equilibrium
  • Maintenance and control of the center of gravity
  • Achieving and maintaining an upright posture

Sensory Systems and Balance Control

  • Visual system
    • Info regarding head position relative to environment
    • Orientation of head to maintain level gaze
    • Direction and speed of head movements
    • Sometimes vision inputs are called upon to work more if proprioceptive or vestibular systems are not working
    • Likewise, visual inputs can be inaccurate as when having the illusion of movement when standing near a bus that starts to move – you feel like you are moving in the opposite direction
  • Somatosensory system
    • Position and motion of the body and parts relative to each other and surface.
    • Muscle proprioceptors are muscle spindle, Golgi tendon organ, joint receptors, skin mechanoreceptors – all to tell us where we are in space
    • Sometimes the inputs are not sufficient to help us maintain balance (standing on a moving boat)
  • Vestibular
    • Information about the position and movement of the head in regard to gravity and inertial forces.
    • Receptors are located in the inner ear; semicircular canals (SCCs)
    • Example: walking while moving head; standing and quickly looking for an object requiring head movement
    • Sensory Organization for Balance Control
      • All 3 systems work together to produce a sense of orientation and movement.
      • Integration of all input is in the cerebellum, basal ganglia, and other motor areas
      • Somatosensory is quickest followed by visual and vestibular
      • When one system does not work, one other area or both may compensate – we use this for basis for treatment programs

Types of Balance Control

  • Feedforward (open loop) – movements that occur too fast to rely on sensory feedback. This is reactive or anticipatory; postural control
  • Anticipatory – activation of postural muscles in advance of a skill movement – core followed by arm or leg movement. E.g. reaching into cabinet or picking up something from floor
  • Closed loop – precision movement requiring feedback. Sitting on ball, walking on balance beam

Motor Strategies for Balance Control

  • Ankle strategy (anteroposterior plane) – small perturbations, slow, movement at ankle to keep COM in a stable position. Muscle activation distal to prox – forward displacement activates gastrocnemius then the hams then paraspinals

  • Weight-shift strategy (lateral plane) – one leg to the other

  • Suspension strategy – flex the hips and knees to quickly lower the body

  • Hip strategy – moderate perturbation force at the hips or pelvis. For example, with a force posterior on the pelvis, the body sways forward by prox to distal action of abdominals, then quads. When the force is pushing forward, the body activates the paraspinals followed by hamstrings. What about walking on a balance beam?

  • Stepping strategy – maximal perturbation force forward or backward step is used to maintain base of support

  • Combined strategies Factors Influencing Selection of Balance Strategies

    • Speed and intensity of the displacing forces
    • Characteristics of the support surface
    • Magnitude of the displacement of the center of mass
    • Subject's awareness of the disturbance
    • Subject's posture at the time of perturbation
    • Subject's prior experiences

Impaired Balance

  • Sensory input impairments – visual, somatosensory, or vestibular
    • Somatosensation may be reduced in peripheral polyneuropathies in aged and DM, increased fall risk.
    • *tend to use Hip strategies in response to balance perturbations.
    • Visual loss from disease, trauma, aging
    • Vestibular loss due to TBI, infections, aging
  • Sensorimotor integration impairments
    • Due to brain injury or CVA
  • Biomechanical and motor output impairments
    • Due to poor posture, joint ROM limitation, decreased muscle performance
    • Due to neuromuscular system impairments
  • Deficits with aging
    • Fall risk
    • Decline in all sensory systems found in aging
    • Speed is slowed, more frequent use of hip strategies, limitations when challenged with greater perturbations and velocity.
    • Deficits from medications

Common Risk Factors for Falls Among the Elderly

  • Muscle weakness
  • History of falls
  • Gait deficit
  • Balance deficit
  • Use of assistive device
  • Visual deficit
  • Arthritis
  • Impaired activities of daily living
  • Depression
  • Cognitive impairment
  • Age >80 years
  • Clinical Tip
    • Divided attention as when a person is doing two tasks simultaneously (i.e., walking while doing a secondary cognitive or motor task) can lead to postural instability and falls, particularly in the elderly.

Outcome Measures for Fall Assessment

  • Berg Balance Test
    • Perfect Score: 56
    • Cut-off Score: <46 (25%, 87% for predicting any fall and 42%, 87% for multiple falls)
  • **Tinetti Performance-Oriented Mobility Assessment
    • Perfect Score: 28
    • Cut-off Score: <20 for elderly (64%/66%) and individuals with Parkinson's disease (76%, 66%)
  • Timed Up-and-Go Test
    • Perfect Score: N/A
    • Cut-off Score: >13.5 seconds (87%, 87%)
  • Four-Square Step Test
    • Perfect Score: N/A
    • Cut-off Score: >15 seconds (89%, 85%)
  • Dynamic Gait Index
    • Perfect Score: 24
    • Cut-off Score: <20 (67%, 86%)
  • Functional Gait Assessment
    • Perfect Score: 30
    • Cut-off Score: <23 (100%, 72%)
  • Five-Times-Sit-to-Stand Test
    • Perfect Score: N/A
    • Cut-off Score: >15 seconds (55%, 65%)
  • ABC Scale
    • Perfect Score: 100%
    • Cut-off Score: <67% (84%, 88%)

Management of Impaired Balance Examination and Evaluation of Impaired Balance

  • Static balance tests (Romberg and modified/tandem Romberg, Single Limb Stance - SLS)
  • Dynamic balance tests (5 times sit to stand – STS)
  • Anticipatory postural control tests (Reaching, catching, lifting, kicking)
  • Reactive postural control tests (strategies – i.e. give perturbation)
  • Sensory organization tests
  • Functional tests (Berg, TUG, Tinetti)

Balance Training

  • Static balance control
  • Dynamic balance control
  • Anticipatory balance control
  • Reactive balance control

Category of Balance Assessment Clinical Tests/Measures* Interventions if Deficits Present

  • Static
    • Observations of patient maintaining different postures; Romberg Test; sharpened (tandem) Romberg ; Single-Leg Stance Test; Stork Stand Test
    • Vary postures; Vary support surface; Incorporate external loads
  • Dynamic
    • Observations of patient standing or sitting on unstable surface or performing postural transitions and functional activities; Five-times-sit-to-stand test (5 × STS)
    • Moving support surfaces; Move head, trunk, arms, legs; Transitional and locomotor activities
  • Anticipatory (feedforward)
    • Observations of patient catching ball, opening doors, lifting objects of different weights; Functional Reach Test; Multidirectional Reach Test: Star Excursion Balance Test; Y- Balance Test
    • Reaching; Catching; Kicking; Lifting; Obstacle course
  • Reactive (feedback)
    • Observation of patient's responses to pushes (small or large, slow or rapid, anticipated and unanticipated); Pull Test; Push and Release Test (PRT); Postural Stress Test
    • Standing sway; Ankle strategy; Hip strategy; Stepping strategy; Perturbations
  • Sensory organization
    • Clinical Test of Sensory Integration on Balance Test (CTSIB)
    • Reduce visual inputs; Reduce somatosensory cues
  • Balance during functional activities
    • CTSIB, Balance Error Scoring System (BESS) or modified; Berg Balance Scale (BBS); Timed Up and Go Test (TUG): Tinetti Performance- Oriented Mobility Assessment (POMA)
    • Functional activities; Dual or multitask activities (e.g., walking with secondary cognitive or motor task)
  • Safety during gait, locomotion
    • Community Balance and Mobility Scale; High Level Mobility Assessment (HiMat)
      Balance within stability limits, environmental modifications, assistive devices, external support Sensory organization Balance during functional activities Safety during gait, locomotion, or balance

Balance Assessments and Interventions Health and Environmental Factors

  • Low Vision
    • Encourage regular eye examinations with adjustments to lens prescriptions and cataract surgery, if necessary.
    • Wearing a hat and sunglasses in bright sunlight, taking extra precautions when it is dark, and making sure lights are on when walking about the house at night are other recommendations.
    • Advise patients to avoid using bifocal glasses when walking, because single lens glasses are safest for improving depth perception and contrast sensitivity, especially on stairs.
  • Sensory Loss
    • For individuals with sensory loss in the legs, caution them to take extra care when walking on soft carpet or uneven ground and use a cane or other device if necessary.
    • Recommend that they wear firm rubber shoes with low heels.
    • Regular medical examinations should be encouraged to ensure that a patient’s blood glucose levels and other factors (i.e., cholesterol, lipids) are under control to minimize damage to sensory nerves from diseases such as diabetes and peripheral vascular disease.
    • Advise patients to seek medical attention if they experience any symptoms of dizziness.
  • Medications
    • Patients should be educated about the influence of certain medications, such as sedatives and antidepressants, on their risk of falling.
    • For example, if such medications are used at night as a sleep aid, an individual should take extra precautions when getting up to use the bathroom.
  • Clinical Tip - Fall Risk
    • According to current best evidence, an exercise program to reduce risk of falls should include at least 2 hours per week devoted to exercises and activities to improve balance.
    • Exercise programs that incorporate multiple types of exercise, such as balance training, strength/resistance training, and constant repetitive movements through all 3 planes (e.g., tai chi or square stepping), are effective for reducing both rate of falls and risk of falling.
    • Although walking has many health benefits, the time devoted to a walking exercise program should be in addition to time spent in balance training and not a substitute for it.
    • Evidence-Based Balance Training Programs for Specific Musculoskeletal Conditions

Balance Progression

  • BODY STABLE BODY TRANSPORT
  • CLOSED
    • Maintaining balance in sitting on bed while caregiver combs hair
    • Rolling over in bed; Sit
  • OPEN
    • Maintaining balance in a moving elevator
    • Carrying a tray of food or drinks from the kitchen to the living room, using the same tray and same route each time intertrial variability
    • Maintaining sitting balance on different chairs in the room
      Ankle sprains – SLS balance on unstable surfaces in post acute phase for static and dynamic balance control.