2010 Sure Step

A Multi-Factorial Falls Intervention

An Evidence Based Prevention Program

Sunday, April 15, 12

Session 20October 23, 2010

Concordia University WisconsinMequon, WI

2010 WOTA CONFERENCE


Sandra Ceranski, MS, OTR/L

Carol Dickert, MS, OTR/L, LPTA

Carol Pociecha-Palm, MRE, OTR/L


LEARNING OBJECTIVES

• Discuss the theoretical base of Sure Step as a multi-factorial falls intervention.

• Discuss background and main elements of the Sure Step algorithm.

• Practice administration, scoring and interpretation of selected screens

• Discuss the clinical application and reimbursement perspectives in participant’s practice settings.

© Sandra Ceranski, MS, OTR


• Multi-factorial falls intervention developed 2001

• Jane Mahoney, MD and Terry Shea, PT

• Adapted from evidence based guidelines published by AGS, BMS and AAOS

SURE STEP IS...



SURE STEP INCLUDES

• In home fall risk assessment using detailed algorithm

• Follow-up in home visit with recommendations

• Referrals and recommendations for client, Physician/Primary Care and Therapists

• Monthly phone contacts for 12 months© Sandra Ceranski, MS, OTR


ALGORITHM

“A step-by-step procedure for solving a problem”

(Merriam-Webster online)



• 25 risk factor “areas” to measure through screening/assessment processes

• Medication, risky behavior, environment, vision, cognition, balance, gait and other factors

• Triggers based on measures WFL or not WFL

• Recommended “Action to Take”

• Recommendations for “Health Professionals”

ALGORITHM



STEP BY STEP PROBLEM SOLVINGRisk Factor Area Triggers Action to Take &

Recommendations

• Medications/OTC

• Benzodiazpenes

• Sleepers

• Antidepressants

• Neuroleptics

• Allergy Med

• Use of medication

• Class

• Education on risk

• Alternatives

• Discuss with MD

• ↓ dose as able

• Avoid



Mahoney, et al. 2005

POTENTIAL COST SAVINGSNursing

Home Costs$176/day was cost of NH in WI in 2004

Cost savings from reduced NH stay by 50 days = $8,800/person

HospitalStays

$15,000 avg. cost of older adult in WI 2002$15,000 cost savings by averting one hospitalization per year

Cost of Fall The average cost of a prevented fall has been estimated at $1,900

Effective select

45 % fewer falls for person with MMSE <28 with live in caregiver


POSTURAL STABILITY

A fall, or not falling, is not an event...it’s a process

© Carol Dickert, MS, OTR, PTA


PROCESS INVOLVES 3 COMPONENTS

• Sensory Input

• Central Processing

• Effector Output



COMPONENTS OF POSTURAL CONTROL

©2006 Sure Step Training Manual Mahoney, Shea, Schwalbe, Cech

Musculoskeletal

Strength

Biomechanical

Effector Output

Cognition

CNS Pathways

Medications

Central Processing

Visual

Vestibular

Proprioceptive

Sensory Input

Environment


SENSORY INPUT

“Our Sensory Systems take in Information from the environment regarding our body’s position in space, then sends that information to the Central Nervous

System (the Spinal Cord and Brain).”



CENTRAL PROCESSING

The brain takes the information that is received from the Sensory Input...processes that information...and

determines an appropriate response.



EFFECTOR OUTPUT

Nerves carry information regarding the appropriate response from the brain to the muscles & joints. The muscles respond by making changes/responses that

sustain balance & equilibrium for the Body.



WHAT CAN GO WRONG?



SENSORY INPUT

VISION



VISION

As we age our Visual Acuity changes.We need more time to adjust to darkness. Young adults

can adjust to the dark almost instantaneously. Older adults require up to 15-20 minutes for the eyes to adjust

to the dark



VISION

Depth Perception - Significantly different visual ability in the eyes will cause unsafe depth

perception. Problems with depth perception cause falls risk, especially on stairs.



VISION

Multifocal Lenses - Bifocals or Trifocals. Progressive lenses impair depth perception on stairs if you don’t

look through the correct level in the lense. This problematic if the person cannot perform adequate

cervical flexion due to limited ROM/Pain.



SENSORY INPUT

VESTIBULAR SYSTEM



VESTIBULAR SYSTEM

The inner ear allows a person to sense motion & the position of

the head in space.



DISORDERS OF THE VESTIBULAR SYSTEM

•Meniere’s Disease

• Labyrinthitis

• Benign Positional Vertigo

• Ear Infections

•Tumors

•Trauma



VESTIBULAR PROBLEMS MAY BE WORSE

• in crowded areas

• when turning the head

• in the dark

• rocking, spinning and/or up-down movement



SENSORY SYSTEM

PROPRIOCEPTION



PROPRIOCEPTION

The Somatosensory System consists of motion, position & pressure sensors in the joints, muscles & skin. These

sensors provide tactile & positional information to enable us to sustain postural control/balance.



CAUSES OF PROPRIOCEPTIVE PROBLEMS

• Peripheral Neuropathy

• Loss of Vibratory Sense

• Loss of Light Touch & Joint Position Sense



COGNITION

CENTRAL PROCESSING



COGNITION

• As cognition declines, the incidence of falls increases. There is a direct correlation between decreased cognitive abilities and increased falls & injury.

• The higher levels of cognition – executive functions are key in the patient’s abilities in safety judgment/ safety awareness.

• As executive function declines, patients engage in more risk behaviors during their ADLs/ IADLs/ MRADLs.



CENTRAL NERVOUS SYSTEM PATHWAYS



DISEASE THAT IMPEDE CNS PATHWAYS

• Cerebrovascular Accident

• Brain infections or abscesses

• Multiple Sclerosis

• Parkinsons Disease

• Degenerative Syndromes (i.e. alcoholism)

• Depression (↓attention to the environment, slowed cognitive & motor reactions)

• Head Trauma

• Heart conditions (i.e. CHF, Abnormal Rhythms, ↓Blood flow to the brain)



MEDICATIONS

Psychotropic medications affect balance because they decrease alertness to the environment and

slow the rate of central processing.



MEDICATIONS

When a young adult takes a medication, half of that medication remains in their body 1 day later. When an older adult takes a medication, half is in their body 1

WEEK later. This causes a significant cumulative effect.



EFFECTOR OUTPUT



MUSCULOSKELETAL

Unsafe Balance/ Stability - The Sure Step Program administers

several balance & gait tests.



INADEQUATE EQUILIBRIUM AND

RIGHTING REACTION



EQUILIBRIUM

The body’s ability to sustain the center of gravity at midline



The body’s ability to return the center of gravity to midline/ right itself when displaced beyond its

limits of stability.

RIGHTING REACTIONS



INADEQUATE EQUILIBRIUM AND RIGHTING REACTIONS

• Tripping Falls

• Slipping Falls

• Reaching (Center of Mass) Falls



LIMITS OF STABILITY


• “Limits of Stability” is how far the body can sway without taking a step.

• Moving the Center of Gravity beyond these limits may cause falls during ADLs/ IADLs/ MRADLs.


• 8° Forward

• 4° Backward

• 8° Laterally Left & Right


LIMITS OF STABILITY


STRENGTH

• Decreased hand strength is one indicator of increased risk for falls.

• Lower extremity strength is essential in preventing falls. All mobility skills (sit to stand, transfers, ambulation, stair climbing, etc.) require adequate LE strength.



BIOMECHANICAL

• Improper footwear is a fall risk.

• In general the best is a firm, thin soled shoe with good support and good tread on the bottom.

• Slippers, stocking feet, and bare feet should be avoided.



FOOT DEFORMITIES

• Tendonitis

• Plantar Fasciitis

• Heel Spurs



ABNORMAL GAIT PATTERNS• Decreased Step Height & Length

during Gait Cycle

• Asymmetrical Gait (Example: “stiff” hip/ knee w/ hiking to clear floor)

• Lack of Continuity during Gait

• Antalgic (Painful) Gait Pattern

• Trendelenberg (Gluteus Medius) Gait Pattern

• Hemiplegic Gait Pattern

• Parkinsonian Gait Pattern

• Scissors Gait Pattern (due to Spastic Hip Adductors)

• Foot Drop Gait w/ ↓Ability to Dorsiflex the Ankle



Sure Step Algorithm©2006 Sure Step Training Manual Mahoney, Shea, Schwalbe, Cech


Measurement Areas to distinguish

Action to Take &Recommendations

2 or more falls in year prior1 fall & history of near falls or imbalanceAcute infection related to falls (UTI, pneumonia, etc.)Medical conditions: Stroke, LE arthritis, LE fractures & Neuropathy

If ≥ fall risk factor

Educate patient and caregiver regarding # risk factors means greater riskCaution ill or med. changesEnvironmental changesUse assistive deviceNotify Physician

FALL RISK FACTORS

© Carol Pociecha-Palm, OTR




Current Assistive Equipment

CURRENT ASSISTIVE EQUIPMENT





Residence:

Senior apartmentApartment (not senior housing)

Live alone or with someone (describe)

RESIDENCE




from measurement


Fall History

1. ______________________

2. ______________________

3._______________________

If Fall Ask patient to discuss with physicianEducate patient and cargiverTripping/slipping fallsFalls with movementFalls with rising

FALL HISTORY





“How confident are you that you can do___without falling?” (LC, FC...) Risky: Y; N

Meal PrepShoppingBathingWalking on snow and ice

Any potentially risky IADL/ADL

Any non-risky IADL/ADL with “Not at all confident”

EducationTask specific modifications:

increased supervisionhome modificationtask avoidancemeals on wheels

IADL’S, MOBILITY ADL’S AND CONFIDENCE





PetsPoor day or night lightingNocturiaBifocals, trifocals, progressive lenses

If patient does any behavior

Recommend OT for modifying behavior & techniques with ADL’s/IADL’sNocturia (decrease evening water intake, no caffeine after 5:00 pm

RISKY BEHAVIORS





What type(s) of physical activity do you get?

Describe amount & type:

TYPE OF PHYSICAL ACTIVITY





Do you have any pain with walking, doing exercises, or performing normal activities?Rate pain 0-10 _____Describe:

Current treatment for pain?

Past treatment for pain?

If yes Ask patient to discuss with physicianRecommend PT/OT for pain managementDiscuss and encourage types of exercise that patient is already doing to alleviate pain

PAIN



Measurement Areas to distinquish


During the past month, have you often been bothered by:

1. Little interest or pleasure in doing things?

2. Feeling down, depressed or hopeless?

If > Yes to 1 or 2 Advise patient to discuss with MD, as it slows recovery and raises fall risk.

Notify MD-phone call is warranted if patient answered “yes” to both questions #1 and #2 on the Two-Question Depression Scale.

Two-Question Depression Screen



Measurement Triggers Action to Take &Recommendations

VAMC SLIMS ExaminationWhat is the highest level of education completed?

High School Education?Less than High School?

If score < 27 and has high school education

or < 25 if less than high school education

Discuss with patient and caregiver regarding raised fall risk, need for supervision, etc.Need for supervisionConsider further evaluation for cognitive impairment and treatment as appropriateConsider evaluation for reversible causes of cognitive impairment B-12 etc.

VAMC SLUMS






Vitamins and Diet1.Calcium (Supplement & Diet)2.Vitamin D3.Multivitamin4.When was your last Bone Mineral Density Test?

If Calcium < 1200 mg/day

If Vitamin D < 800 iu/day

Recommend daily elemental calcium intake of 1200 mg/dayRecommend 1 multivitamin per dayRecommend daily intake of 800-1000 iu Vitamin d per day as recommended in 2008.

VITAMINS AND DIET



MEDICATIONRisk Factor Area Triggers Action to Take &

Recommendations

• Sleep Medication

• Antidepressants

• Anxiety

• Antipsychotic

• Allergy Med/spray

• Dizziness

• Neuropathic pain

• Bladder control

• Alcohol use

• Use

• Dose

• Class

• Educate on risk

• Avoid or minimize

• Lowest does

• Alternatives

• Discuss with MD



VISIONRisk Factor Area Triggers Action to Take &

Recommendations

• Eye Exam

• Type of lenses

• Use with walking

• Vision test

• Visual field

• <20/40

• Difference between eyes

• No visit in past year

• Multi-focal lenses

• Good lighting

• Environment

• Mobility device

• Caution stairs, curbs

• See eye doctor

• Refer Vision & OT

• Single vision lenses

• Cataract surgery



FOOT DEFORMITYRisk Factor Area Triggers Action to Take &

Recommendations

• Observe with shoes off

• Hammer toes

• Bunions

• Abnormal • Refer to podiatrist for balance and gait

• Extra depth shoes

• Ankle foot orthotics



ANKLE ALIGNMENTRisk Factor Area Triggers Action to Take &

Recommendations• Observe during standing and

walking with shoes on and off• Not corrected

with shoes on• Refer to Podiatrist or PT



FOOTWEARRisk Factor Area Triggers Action to Take &

Recommendations

• High heels

• Floppy slippers

• > 1 in. heels/soles

• Large tread

• Yes to any • Avoid

• Firm thin soles

• Podiatrist

© Sandra Ceranski, MS, OTRSunday, April 15, 12

VIBRATIONRisk Factor Area Triggers Action to Take &

Recommendations

• Lie down

• 128 Hz tuning fork

• Toe and ankle with eyes closed

• If absent • Education

• Cane or AD

• Extra caution

• Diagnosis



ORTHOSTASIS

• A patient with Orthostatic Hypotension may experience Syncope (pass out), or may fall due to Orthostatic Hypotension without fainting.

• To measure, use Blood Pressure Cuff & Stethoscope to get Blood Pressure reading. Record Pulse Rate.



ORTHOSTASIS

• “Normal” Blood Pressure is 120/80. “Normal” Pulse Rate is 60 beats/ minute.

• Record Blood Pressure & Pulse Rate after patient lies supine for 3-5 minutes. Then standing position for 1 minute. If the Systolic (Top) number drops by >20 points, Orthostasis is problematic.



ORTHOSTASIS

Alert the Physician:

" Systolic reading is too high >180

" Systolic reading is too low <100

" Diastolic reading is too high >90



SURE STEP ALGORITHM

• Let’s learn by doing

•What do you want to learn more about?

•What could you incorporate into your practice?



Date post:	08-Feb-2017
Category:	Documents
Upload:	carol-pociecha-palm
View:	323 times
Download:	1 times

2010 Sure Step

Documents