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Various risk factors for falls in older adults, both intrinsic and extrinsic. It also explores evidence-based tests and assessments for balance and fall risk, including screening tools for cognitive impairment, functional tests, and questionnaires. The document emphasizes the importance of addressing modifiable risk factors through therapy and patient education.
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Balancing Act: Functional Tests and Assessments for Balance and Fall Risk
PDH Academy Course #PT- 4 CE Hours
Course Abstract Census data tells us that elderly populations are growing at an unprecedented rate – and we know as therapists that the elderly have the greatest risk of fall-related injury or death. This course presents a discussion of risk factors for falls, followed by an examination of evidence- based tests and assessments for balance and fall risk, including screening tools for cognitive impairment, functional tests pertaining to balance and fall risk, and questionnaires that assess confidence with mobility and concern for falling. It concludes with an overview of fall-related resources.
NOTE: Links provided within the course material are for informational purposes only. No endorsement of processes or products is intended or implied.
Approvals To view the states that approve and accept our courses, visit https://pdhtherapy.com/physical- therapy/
Target Audience & Prerequisites PT, PTA, OT, OTA – no prerequisites
Learning Objectives By the end of this course, learners will:
Timed Topic Outline I. Statistics: Falls and Fall-Related Injuries (20 minutes) II. Risk Factors for Falls (40 minutes) Age-Related Physiological Changes that Contribute to Fall Risk, Relevant Research, Modifiable Risk Factors for Falls, Alignment and Posture III. Importance of Testing, When to Test, and Which Tests to Choose (10 minutes) Importance of Testing, When to Test, Which Tests to Choose IV. Screening Tools: Cognition (10 minutes) Test and Assessment Overview V. Screening and Assessment Tools: Balance and Fall Risk (90 minutes) Databases on Functional Testing, Test and Assessment Overview, American Physical Therapy Association Section Recommendations
VI. Resources for Patients, Caregivers and Health Care Workers (20 minutes) Professional Resources, Evidence-Based Community Fall Prevention Programs VII. Conclusion and Appendix (30 minutes) VIII. References and Exam (20 minutes)
Delivery Method Correspondence/internet self-study, with a provider-graded multiple choice final exam. To earn continuing education credit for this course, you must achieve a passing score of 80% on the final exam.
Cancellation In the unlikely event that a self-study course is temporarily unavailable, already-enrolled participants will be notified by email. A notification will also be posted on the relevant pages of our website.
Customers who cancel orders within five business days of the order date receive a full refund. Cancellations can be made by phone at (888) 564-9098 or email at support@pdhacademy.com.
Accessibility and/or Special Needs Concerns? Contact customer service by phone at (888)564-9098 or email at support@pdhacademy.com.
Course Author Bio and Disclosure Andrea Perrea, MPT, DHS, GCS, CSCS, is a licensed physical therapist with over 23 years of clinical experience, primarily in home care and outpatient therapy, and over 17 years teaching experience. She holds a doctorate degree in Health Science with emphasis in education and geriatrics. She is a Certified Geriatric Specialist through the American Physical Therapy Association, a Certified Strength and Conditioning Specialist through the National Strength and Conditioning Association, and a member of the American Physical Therapy Association, the APTA Geriatrics Section, and the National Strength and Conditioning Association.
Dr. Perrea has taught more than 300 continuing education courses since 2000. She taught as adjunct faculty for the Missouri Western University in the PTA program. In 2012 she instructed for the Missouri Alliance for Home Care and the Indiana Home Care Association. Dr. Perrea presented at the 2015 Rehab Summit in Orlando FL. She currently teaches courses on the following topics: Functional Testing and Skilled Documentation in Geriatric Therapy, Exercise Programs for Frail Elderly, Balance Assessments and Fall Prevention Programs, Strength Training for Function: Program Design for Frail to Fit Seniors, and Expand Your Functional Test Toolkit.
DISCLOSURE: Financial – Andrea Perrea received a stipend as an author of this course. Nonfinancial – No relevant nonfinancial relationship exists.
The National Council on Aging (NCOA) also addresses falls in aging populations on their website, stating (NCOA, 2018):
II. Risk Factors for Falls
There are a number of risk factors for falls, which can be divided into two categories: intrinsic and extrinsic.
Intrinsic risk factors are those that are within the body and/or acting upon the body; they may or may not be modifiable.
Extrinsic risk factors are those that are within the environment. They can often be modified or avoided.
Falls are commonly caused by a combination of multiple risk factors, both intrinsic and extrinsic (CDC: Fact Sheet, 2017).
Age-Related Physiological Changes that Contribute to Fall Risk As the body ages, a number of physiological changes take place: while all naturally occur due to the passage of time and aging processes, some can be influenced through lifestyle choices.
The table below (Arking, 1998; Digionvanna, 2004) summarizes how various body systems are impacted by aging, considering both how those physiological changes influence therapy programs in general, and how they affect fall risk. (As you review the table, notice where and how we as therapists can influence these changes – for example, strength training may mitigate decreasing muscle strength.)
Body System Physiological Changes with Aging Impact on Fall Risk and Therapy Programs
Muscular Decreased ability of cell to be stimulated by neuron
Decrease in number of muscle cells (Type II/fast twitch more than Type I/slow twitch)
Decrease in number & size of mitochondria
Decreased muscle strength and muscular endurance
Earlier onset of fatigue
Decreased ability to respond to rapid movements
Decreased ability for power
Decreased function and impaired Activities of Daily Living, especially gait, stair climbing, and sit-to-stand performance
Substitution of muscle groups with exercise and function Skeletal Protein & minerals in bone matrix change
Bone more rigid and brittle
Decrease in trabecular & cortical bone
Thinning of cartilage in joints
Decrease in central region of
Increased risk of fracture
Decreased height
Decreased joint mobility
Joint pain due to thinning of cartilage
Increased rigidity of spine
Postural changes which can limit
Decrease in number of motor neurons
Reflexes slowed
risk of falls or injury due to decreased ability to anticipate changes in the environment (decreased anticipatory postural control)
Inability to enjoy aromas of foods, which can effect nutritional status and overall health
Slowing of voluntary movement
Neuropathy may be present, affecting proprioceptive input from the foot and ankle Vestibular Decrease in number of nerve cells
Decrease in density of hair cells
Decrease in blood flow to the inner ear
Reduction in vestibulocular reflex (VOR)
Issues of dizziness
Vestibular-related disorders (BPPV, Meniere’s disease, Vertigo)
Reduction in VOR affects ability to stabilize vision when the head turns quickly
Vision Decreased transparency of cornea
Cornea becomes flattened
Decreased fluid production
Decreased number and length of cones
Reduced acuity
Decrease in depth perception
Decrease contrast sensitivity
Increase in eye diseases: cataracts, glaucoma, and macular degeneration
Difficulty seeing close objects – need for bifocals
Medication mistakes due to not being able to read dosage and instructions
Decreased adaptation to changing light
Altered perception of body position in space
Narrowing of visual field
Difficulty with visualizing and perceiving surface conditions/environmental hazards
Loss of independence when the person can no longer drive
Larger print needed for handouts
Potential social isolation, depression, decreased activity Hearing Increased ear wax
Decrease in number of several types of cells
Eardrum becomes stiffer
Decreased ability to hear all frequency of sound (especially high frequency)
Decreased ability to localize sound
Increased risk of falls / decreased balance reactions
Potential social isolation, depression, decreased activity Respiratory Weakening of muscles of respiration
Decrease in minute volume due to stiffness of thorax
Decreased vital capacity
Decreased rate of diffusion
Decrease in Forced Expiratory Volume (FEV)
Decrease in max breathing
Increased risk of aspiration and pneumonia
Decreased efficiency of activities
Increased risk of sedentary lifestyle
Decreased maximal VO
Need for additional monitoring of vitals, rest breaks, breathing techniques
Relevant Research Rubenstein et al (2000) analyzed sixteen fall risk factor studies, identifying three top factors: lower extremity weakness, history of falls, and gait or balance deficit. They also emphasized the relevance of advanced age (over 80), cognitive impairment, depression, arthritis, and visual deficits.
Looking specifically at cognitive impairment, Yaffe et al (2001) found that at least 10% of all people older than 65, and 50% of those older than 80, have some form of cognitive impairment. These changes can affect the older person’s ability to anticipate and adapt to changes and hazards in the environment. For example, the incidence of falls in older people with cognitive impairment is more than two times that of cognitively intact people (Allan et al, 2009). And, along with dementia, a diagnosis of depression is linked to higher fall risk (Taylor et al, 2012).
v011108.pdf), which provides a very detailed home safety assessment. For your convenience, I’ve also attached a summary home safety checklist, based on my many years of work in home care, which compiles information from multiple lists: see Appendix.
Alignment and Posture Alignment and posture can impact balance, so you’ll want to keep both in mind throughout the assessment and intervention process.
Alignment incorporating a forward head and rounded shoulders is associated with decreased function in walking, stair climbing, lifting, reaching, dressing, and bathing. It is also linked to susceptibility for vertebral fractures. In contrast, the benefits of proper alignment include:
Anticipatory vs. Reactive Postural Control Anticipatory control is the control used when actions can be planned in advance: examples include recognizing a change in flooring and adjusting accordingly, or walking on a sidewalk, seeing sticks and obstacles like sticks in the way, and changing gait pattern to accommodate the situation.
Reactive control describes the more automatically generated actions that occur when our movements cannot be planned in advance. In other words, they occur in response to an event or events we did not expect. Examples include walking on a road and hitting a patch of black ice, or walking across the lawn and stepping in a hole.
Postural Control Strategies There are at least three distinct postural control strategies that are used to maintain posture and our center of gravity: ankle strategy, hip strategy and step strategy.
Ankle strategy is affected by range of motion, strength at joint, the surface below, and sensation in the feet. We use this strategy if given a gentle nudge when standing to maintain balance.
Hip strategy is determined by the amount of strength and range of motion (ROM) of the hip. It is used in instances where there is more body sway: if you were given a nudge while standing on a narrow beam, you would “break” at the hip to accommodate for the disturbance of your center of gravity.
Step strategy is affected by lower extremity strength and power. If your center of gravity is moved beyond your maximum limit of stability the step strategy comes into play: you are standing on a piece of foam, someone pushes you to the side, and you step in order to maintain an upright position.
Analyzing alignment and posture should be a part of your assessment process; likewise, teaching proper alignment and postural strategies can be incorporated into your patient education and treatments.
III. Importance of Testing, When to Test, and Which Tests to Choose
Importance of Testing Including functional tests and objective measures in documentation has become increasingly important over the last several years. Medicare and other insurance providers are looking for objective data to show need for skilled therapy and to show progress with interventions. As we move toward an era of pay for performance, this will become even more critical.
Functional testing helps to find the strengths and weaknesses your patient may have. In addition to helping to objectively demonstrate the need for skilled treatment, progress with the treatment plan, and need for continued services, it also guides your plan of care, ensuring that it is specific to the individual and their function. Let’s consider an example: I might see in a therapy note that the patient is min assist for upper body dressing, but no documentation as to why they are min assist. It might be because they have limited shoulder range of motion, poor fine motor skills, decreased ability to reach and gather items for dressing, inadequate balance, cognitive deficits, etc. Terms like min, mod, and max assist are objective, but they are not patient specific, and don’t address why the person is at a particular assist level. Functional testing helps us to investigate and pinpoint the “why” – the reason that an individual is having difficulty with basic functions.
The other important benefit of functional testing is motivation. I have found in my own practice that people love numbers, so it can be really helpful to show individuals their scores, explain what each one means, and break down how each will influence your goals. Objective data can also be used to educate patients and family members: to motivate them to participate in therapy, help to strengthen a recommendation, or demonstrate the need for continued treatment in the next phase of rehabilitation. Likewise, when people cannot see how much progress they have made, having objective data to show them this is very helpful. I have often used functional testing during home care, not only to show progress during my episode of care, but also to show why outpatient therapy is recommended.
Keep all of these factors in mind as you read through the functional tests presented in this course.
When to Test Functional tests are commonly completed at the initial physical therapy and occupational therapy evaluations, both to establish a baseline, and to track progress over time.
Since cognitive decline has been shown to play a role in fall risk, it is important to know tools to assess cognition. It is also important for your overall plan of care, as individuals with impaired cognition might take additional time or need caregiver training and involvement in order to meet therapy goals.
Sometimes another discipline, such as speech-language pathology, may have performed a cognitive screen; if that is the case you can refer to their findings. If, however, you suspect some issues with cognition but do not see anything documented in the medical record, you may wish to run a screen of your own. I have included the tools that therapists around the country tell me they use the most often.
Note: Cognitive tests come in multiple languages, so make sure you know the primary language of the individual being tested. A person may score as having a cognitive deficit on one of the tools when they actually just have a language barrier.
Test and Assessment Overview The following tests and assessments will be covered:
Mini-Mental State Examination Purpose / Description: Provides a quantitative assessment of cognitive impairment and tracks changes in cognition over time. The Mini-Mental State Examination includes 11 simple questions grouped into 7 cognitive domains:
Time to Complete: < 10 minutes
Scoring and Score Interpretation: The maximum score is 30. Levels of impairment are as follows (Tombaugh & McIntyre, 1992): 24-30 No impairment 18-24 Mild impairment 0-17 Severe impairment
Is the Test Free: The current version of the test (MMSE-2) is not free to use; it is available for purchase at https://www.parinc.com/Products/Pkey/238.
Montreal Cognitive Assessment (MoCA) Purpose / Description: A brief 30 question cognitive screening tool for mild cognitive impairment. It assesses the following:
There are multiple versions of the MoCA, including one for people who are visually impaired.
Time to Complete: 10-12 minutes
Scoring and Score Interpretation: Scores range from zero to 30: 26 and higher is usually considered normal.
In the initial data study, normal people scored an average of 27.4; people with mild cognitive impairment (MCI) scored an average of 22.1; people with Alzheimer's disease scored an average of 16.2 (Rosenzweig, 2018).
A short training program to better understand the test, as well as its scoring and interpretation, is available at https://www.mocatest.org/.
Is the Test Free: Yes (Must be accessed at https://www.mocatest.org/)
Saint Louis University Mental Status Exam (SLUMS) Purpose / Description: Identifies persons who have dementia or mild neurocognitive impairment. It consists of 11 items testing orientation, memory, attention, and executive function.
Test website: https://www.slu.edu/medicine/internal-medicine/geriatric-medicine/aging- successfully/assessment-tools/mental-status-exam.php
Geriatric Assessment Tool Kit (University of Missouri) http://geriatrictoolkit.missouri.edu/
Both of the above free databases contain a wealth of information on each test, including research, the psychometric properties of each, relevant research, and links to additional information. If the test is freely available, copies are usually available for download; if a fee or special permission is required for use, access information is provided instead.
PTNow (APTA) https://www.ptnow.org/
Available free to members of the APTA, PTNow also provides an extensive database of tests and test information, including psychometric properties and clinical utility. Other resources include full-text access to research articles, access to Cochrane Reviews, and more.
Test and Assessment Overview The following tests and assessments will be covered:
In addition, a summary table is included as a quick reference – see Appendix.
Berg Balance Scale (Berg) Purpose / Description: Measuring static and dynamic balance of older adults. This is a 14 item test that progressively gets more challenging as it goes along. The test should be performed in order. The individual being tested is not allowed to use an assistive device.
Time to Complete: About 15 minutes.
If you are new to the test it can take a while to score due to the multiple levels of scoring per item on the test. I find as therapists get increasingly familiar with the scoring they can complete the test in < 15 minutes.
Special Equipment or Space Needed: Score sheet, stop watch, ruler, footstool or step, 2 standard chairs (one with arms and one without), a shoe or a slipper. This test does not need much space, and can be done in a patient’s room if you are in a facility.
Scoring and Score Interpretation: A five-point ordinal scale ranging from 0-4: “0” indicates the lowest level of function and “4” the highest level. Maximum score for the test is 56.
Related Research: Per Berg et al, scores of less than 45 indicate individual may be at greater risk of falling (1992). Thorbahn and Newton also found that a cutoff of 45/56 discriminated fallers from non-fallers (1996). Likewise, scores of less than 40 were associated with almost 100% fall risk (Shumway- Cook et al, 1997).
Functional Connection / Clinical Importance: The Berg is an excellent assessment to evaluate static and dynamic balance for multiple diagnoses. It can help you to identify impairments or weakness your client has, so that you can use that information to direct the plan of care. The Berg is often used to help make the clinical decision whether a person needs to use an assistive device due to fall risk, and/or to help strengthen a recommendation to use an assistive device or other equipment such as a grab bar. In addition, it can be tied to safety with ambulation and safety with ADL’s. Many components of the Berg are also used as treatment.
While therapists generally tell me they use this test with slightly higher-level individuals as it has some more challenging tasks, it can be used for a wide variety of functional levels – particularly if you feel an individual has the ability to improve with intervention. I have used this test frequently, in both outpatient and home care settings: I find it clearly shows clients their level of safety and ability.
Is the Test Free: Yes (See test form – Appendix)
Timed Up and Go Test (TUG) Purpose / Description: Assessing mobility and fall risk. The TUG tests the ability to rise from a standard arm chair, walk 3 meters, turn, and return to the chair. An individual can use an assistive device for this test but
correlated with knee extensor strength as measured with a dynamometer: the stronger the quadriceps, the faster the TUG score.
Functional Connection / Clinical Importance: I find this test is the one most therapists know about and use in multiple practice settings; however, I also find that many therapists do not perform the test correctly. Pay special attention to the start position, the timing, and measuring 3 meters to keep the test valid.
This test is a great way to get an initial look at transfer ability and gait, which are two very important functional tasks. I perform this test on any individual that qualifies to assess fall risk and get an idea of safety with transfers and gait. Depending on their performance, I can also see if a more detailed gait analysis or balance assessment is needed.
In addition to looking at risk for falls, this test also is measuring efficiency of movement. Efficiency is important in its own right, and can be linked to safety in situations like answering the door, answering the phone, and exiting in case of emergency: people have a sense of urgency when doing those tasks. To take a specific case, I was working with a woman who lived in a senior high rise apartment. She would walk with her walker to the elevator, push the button, and then sit in a chair and wait for the doors to open (it often took some time). When the elevator door opened, she only had so much time to get up from the chair and get herself and her walker into the elevator. She initially had a lot of difficulty with this and it caused her concern that the doors would close on her. I was able to use her TUG score to objectively show her that her efficiency or speed was improving, making getting on and off the elevator safer.
The TUG is also a good test to compare an individual’s ability to walk with different devices, or with a leg brace or ankle foot orthoses (AFO). You can compare and contrast gait with multiple devices or AFO to look at speed and efficiency of movement and safety.
Another important clinical connection: a slow TUG time may be partially responsible for those episodes of incontinence that occur when an individual is unable to get to the bathroom in time. If that is the case, you can discuss the importance of improving TUG time to decrease those episodes.
This test is also clinically important in that it is one of three functional tests the CDC’s STEADI program, which will be discussed in more detail later in this course, uses in screening for fall risk.
Is the Test Free: Yes. No special test form is needed.
30 Second Chair Stand Test Purpose / Description: Testing functional lower extremity strength and detecting normal age-related strength decline.
Place a 17” chair against the wall for safety; the individual you are testing should be seated in the middle of the chair with their arms folded across their chest and feet flat on the floor. Instruct the individual to fully extend hips and knees and come to a full stand (I often demonstrate this). Give the following instructions: “On go, stand up and sit down as many times as you can in 30 seconds”. The timer starts on go and the person stops at 30 seconds or when they can no longer do additional repetitions.
A video of a senior performing this test can be found at https://www.cdc.gov/steadi/materials.html or https://progressivetherapyedu.com/physical-occupational-therapy-resources/.
Time to Complete: < 5 minutes. You only do one trial due to fatigue.
Special Equipment or Space Needed: 17” chair and stopwatch. Very little space is needed.
Scoring and Score Interpretation: An individual’s score is the number of full stands they can do in 30 seconds (if they are more than halfway up at the end of 30 seconds they get credit for the last repetition).
Below are the middle 50% of test scores.
Test Norms (Rikli & Jones, 2013) Age 60-64 65-69 70-74 75-79 80-84 85-89 90-
Men 14 - 19 12 - 18 12 - 17 11 - 17 10 - 15 8 - 14 7 - 12 Women 12 - 17 11 - 16 10 - 15 10 - 15 9 - 14 8 - 13 4 - 11
Along with the with the test score, you should also document items related to performance and safety: although you will not cue individuals on form prior to testing, you can make note of any variations and incorporate that information into your plan of care. For example, some individuals may have difficulty controlling the lowering or eccentric portion of the sit-to-stand movement. Others may have difficulty keeping centered on the chair, or have difficulty with balance upon standing. I have seen some individuals put their feet very far apart to perform the movement, and others put their feet together. These are all things to note in your documentation, as they highlight some safety issues and will direct your transfer training.
If a person cannot get up from the 17” chair with their arms crossed, their standardized test score is “0”. Rikli and Jones (2013) mention in their textbook, Senior Fitness Test Manual, that there are some adaptations that can be used in the context of a score of “0” – be sure to document both the original score and how you adapted the test. It is particularly important to document the adaptation used so you can retest in the same way.