Physical therapy to improve functioning of older people in residential care facilities

Predictive accuracy of performance oriented mobility assessment for falls in older adults: A systematic review

Background: Performance Oriented Mobility Assessment (POMA) is a commonly used screening tool for identifying patients at risk of falling. The purpose of this systematic review was to determine the overall predictive accuracy of POMA for falls in community-dwelling older adults. This review could provide useful information to use POMA in both research and clinical settings.

Methods: In this study, PubMed, EMBASE, CINHAL, Cochrane Library, EBSCO, and SCOPUS were searched to identify studies published from 1987 to 2017 that aimed at validating POMA and reporting predictive value with sufficient data to calculate sensitivity and specificity. The methodological quality of the selected studies was assessed using the Quality Assessment of Diagnostic Accuracy studies (QUADAS-2).

Results: Of the 121 identified studies, 12 met the inclusion criteria and were entered in the final analysis. Fall rate ranged from 5% to 61% in the included studies. The POMA cutoff point for discriminating fallers from non-fallers varied from 15 to 26. Sensitivity and specificity of the POMA ranged from 24-91 to 37-97, respectively.

Conclusion: Due to heterogeneity of the type of studies, participants, the definition of fall, and use of different versions of POMA, it was not possible to determine a specific cutoff point for POMA. In addition, using the same version and scoring method of POMA and controlling the significant potential confounders (eg, age, gender, and comorbidities) would provide better information about the predictive accuracy of POMA for falls in older adults.

Ottawa Panel Evidence-Based Clinical Practice Guidelines for Post-Stroke Rehabilitation

BACKGROUND AND PURPOSE

The purpose of this project was to create guidelines for 13 types of physical rehabilitation interventions used in the management of adult patients (>18 years of age) presenting with hemiplegia or hemiparesis following a single clinically identifiable ischemic or hemorrhagic cerebrovascular accident (CVA).

METHOD

Using Cochrane Collaboration methods, the Ottawa Methods Group identified and synthesized evidence from comparative controlled trials. The group then formed an expert panel, which developed a set of criteria for grading the strength of the evidence and the recommendation. Patient-important outcomes were determined through consensus, provided that these outcomes were assessed with a validated and reliable scale.

RESULTS

The Ottawa Panel developed 147 positive recommendations of clinical benefit concerning the use of different types of physical rehabilitation interventions involved in post-stroke rehabilitation.

DISCUSSION AND CONCLUSION

The Ottawa Panel recommends the use of therapeutic exercise, task-oriented training, biofeedback, gait training, balance training, constraint-induced movement therapy, treatment of shoulder subluxation, electrical stimulation, transcutaneous electrical nerve stimulation, therapeutic ultrasound, acupuncture, and intensity and organization of rehabilitation in the management of post stroke.

Gait speed in ambulant older people in long term care: a systematic review and meta-analysis

BACKGROUND

Gait speed, recently proposed as the sixth vital sign of geriatric assessment, is a strong predictor of adverse outcomes. Walking faster than 1.0 m/s is associated with better survival in community-dwelling older adults, and a recent meta-analysis of older adults in clinical settings estimated usual gait speed to be 0.58 m/s. Here, we aimed to review gait speed values for long term care residents.

METHODS

Relevant databases were systematically searched for original research studies published prior to December 2012. Inclusion criteria were participants living in long term care, mean age >70 years, and gait speed measured over a short distance. Meta-analysis determined gait speed data adjusting for covariates including age, sex, and cognition.

RESULTS

Final data included 2888 participants from 34 studies. The percentage of residents ineligible because of inability to mobilize was stated in only 1 study. Of the 34 studies, 22 reported cognitive status using the Mini-Mental State Examination. Usual pace and maximal pace gait speeds were determined separately using a random effects model. No association between gait speed and covariates was found. Usual pace gait speed was 0.475 m/s (95% confidence interval 0.396-0.554) and maximal pace was 0.672 m/s (95% confidence interval 0.532-0.811).

CONCLUSIONS

In ambulant older people in long term care, gait speed is slow but remains functional. However, since many residents are likely to have been ineligible to participate in assessments, these results cannot be generalized to the long term care population as a whole.

Reliability and validity of the Turkish version of the Performance-Oriented Mobility Assessment I

The Performance-Oriented Mobility Assessment (POMA)-I is widely used assessment tool for evaluation of balance and gait properties. The aim of this study was to translate POMA-I to Turkish and to assess its reliability and validity. People with amputated lower extremities using prosthetics, those who underwent orthopedic surgery within the last 6 months, those dependent on wheel chairs and also bed-ridden patients, subjects with dementia and Alzheimer’s disease, and illiterate people were excluded. After translation into Turkish, the Turkish version of the scale was applied on the participants at 2-week intervals. Volunteers ≥65 years of age were enrolled in the study. Internal consistencies of POMA subscale scores of postural balance and gait, and total score were calculated using Cronbach’s α coefficient. The Turkish version was evaluated with respect to inter- and intrarater reliability and test–retest reliability intraclass correlation coefficient (ICC). For validation, Pearson’s correlation coefficient between POMA and Berg Balance Scale (BBS) and Timed Up and Go Test (TUGT) was estimated. Eighty participants enrolled in the study with a mean age of 76.5 ± 6.75 years. In the reliability evaluation of the scale, considering postural balance, gait, and total score, Cronbach’s α coefficients were found to be 0.72, 0.83, and 0.88, respectively. ICCs were detected above 0.70 for test–retest reliability and also for interrater and intrarater reliability. In validation study POMA total score had a strong positive correlation with BBS total score (r = 0.86, p < 0.0001), and also a negative correlation with TUGT (r = −0.75, p < 0.0001). According to the results of this study, the Turkish version of the POMA-I scale has been found to be a reliable and a valid scale for elderly Turkish people.

Fall management in Alzheimer-related dementia: a case study

BACKGROUND AND PURPOSE

Nursing home residents with dementia are at an increased risk of falls. This case report describes a physical therapist's approach to fall management in a patient with Alzheimer's disease in a long-term care facility.

CASE DESCRIPTION

An 85-year-old female with Alzheimer's disease began to experience impaired balance and weakness resulting in gait deviations and falls. The combination of clinical findings, scores on several clinical measures, and fall history classified her as being at high risk for future falls.

INTERVENTION

The physical therapy fall management program included lower extremity and core therapeutic exercise, balance, gait, and assistive device training, and caregiver instruction in the form of a functional maintenance program (FMP) with focus on activities that activated the implicit memory system while emphasizing aspects of communication that are typically preserved in patients with dementia.

OUTCOMES

After 4 weeks of twelve 30 minute sessions, the patient's Tinetti Assessment Tool score increased from 8/28 to 16/28 and Berg Balance Scale score from 7/56 to 19/56. The number of documented incident reports related to falls decreased from 2 to 0 in a 4-week period of time. On the International Classification of Functioning, Disability, and Health, the patient improved in 4 areas of the Impairments of Body Functions domain, in 12 areas of the Activity Limitations and Participation Restriction domain, and in 3 areas of the Environmental Factors domain.

DISCUSSION

Positive functional outcomes were achieved through a modification of typical fall prevention interventions that took into consideration the patient's decreased cognition, communication deficits, and behavior problems.

Factors associated with physiotherapy provision in a population of elderly nursing home residents; a cross sectional study

Background

Although physiotherapy (PT) plays an important role in improving activities of daily living (ADL functioning) and discharge rates, it is unclear how many nursing home residents receive treatment. Furthermore, there is a lack of insight into the determinants that influence the decision for treatment. In this study, we investigated how many nursing home residents receive PT. In addition, we analysed the factors that contribute to the variation in the provision of PT both between nursing homes and between residents.

Methods

A random sample of 600 elderly residents was taken from a random sample of 15 nursing homes. Residents had to be admitted for rehabilitation or for long-term care. Data were collected through interviews with the nursing home physician and the physiotherapist. Multilevel analysis was used to define the variation in the provision of PT and the factors that are associated with the question whether a resident receives PT or not. Furthermore the amount of PT provided was analysed and the factors that are associated with this.

Results

On average 69% of the residents received PT. The percentage of patients receiving treatment differed significantly across nursing homes, and especially the number of physiotherapists available, explained this difference between nursing homes. Residents admitted to a somatic ward for rehabilitation, and male residents in general, were most likely to receive PT. Residents who were treated by a physiotherapist received on average 55 minutes (sd 41) treatment a week. Residents admitted for rehabilitation received more PT a week, as were residents with a status after a total hip replacement.

Conclusion

PT is most likely to be provided to residents on a somatic ward, recently admitted for rehabilitation to a nursing home, which has a relatively large number of physiotherapists. This suggests a potential under-use of PT for long-term residents with cognitive problems. It is recommended that physiotherapists reconsider which residents may benefit from treatment. This may require a shift in the focus of physiotherapists from 'recovery and discharge' to 'quality of life and well-being'.

Balance, aging, and osteoporosis: effects of cognitive exercises combined with physiotherapy

OBJECTIVE

To evaluate whether performing cognitive tasks while exercising influenced the effects of an exercise program designed to reduce the risk of falling in elderly women with osteoporosis.

METHODS

We included 68 osteoporotic women older than 70 years of age (mean age, 73.5 years+/-1.6) who followed a program of 12 sessions of balance, coordination, and ambulation exercises designed to lessen the risk of falling. The patients were divided into two groups based on proximity to the study centers. The groups were randomly allocated to the exercise program alone (N=31, single-task group) or to the same program combined with cognitive tasks performed while exercising (N=37, dual-task group). Timed up-and-go tests and one-leg balance (OLB) tests were done at baseline, at the end of the exercise program, and 3 months after the end of the exercise program.

RESULTS

In both groups, the exercise program produced significant improvements in up-and-go and OLB times. Additional improvements occurred over the first 3 months following the program. Adding cognitive exercises did not provide added efficacy.

CONCLUSIONS

Balance was improved after the exercise sessions. The improvements were clinically significant and increased over time.

Concurrent validity of the Berg Balance Scale and the Dynamic Gait Index in people with vestibular dysfunction

BACKGROUND AND PURPOSE

The Berg Balance Scale is a reliable and valid measure that is used to assess characteristics of balance. The Dynamic Gait Index is a relatively new measure that has been used to record dynamic gait tasks in people with vestibular dysfunction. The purpose of the present study was to determine the concurrent validity of the Dynamic Gait Index with the Berg Balance Scale in people with vestibular disorders.

METHOD

A retrospective review of the charts of people who met the criteria of having completed both the Berg Balance Scale and the Dynamic Gait Index during their first physiotherapy visit. Seventy patients (19 male, 51 female) were identified through the retrospective review of the charts of people referred for vestibular rehabilitation with varying diagnoses of vestibular and balance dysfunction. All were seen at a tertiary medical centre in an outpatient physiotherapy setting. Their age range was from 14 to 88 years (mean 65 years).

RESULTS

Correlation between the scores on the Dynamic Gait Index and the Berg Balance Scale was moderate but significant by use of the Spearman rank order correlation (r = 0.71; p < 01). No difference was found between scores on the Dynamic Gait Index or Berg Balance Scale based on gender or diagnosis. A significant difference was identified on the Berg Balance Scale between older and younger people with vestibular disorders. Using previously established criteria to determine increased risk of falling, the Berg Balance Scale and the Dynamic Gait Index agreed 63% of the time.

CONCLUSIONS

The moderate correlation between the Dynamic Gait Index and the Berg Balance Scale establishes the concurrent validity of the Dynamic Gait Index in people with vestibular dysfunction. Both these measures provide valuable information to clinicians about patients' functional balance capabilities. However, the lack of perfect correlation indicates that the tests measure different aspects of balance. The Dynamic Gait Index appears to be a more sensitive assessment tool in identifying people with vestibular disorders who are at increased risk for falling, based on currently published criteria.

Group Balance Skills Class for People with Chronic Stroke

BACKGROUND AND PURPOSE

A history of stroke increases risk of falls even years after stroke, and subsequent fear of falling causes individuals to reduce their activities. The purpose of this case series is to describe a group balance skills class for individuals poststroke living in the community, and to assess the feasibility and outcomes of this class. EXAMINATION AND INTERVENTION: Twice a week for 8 weeks, 4 individuals >6 months poststroke attended a group class designed to challenge their balance. The group was carried out under the supervision of one physical therapist assisted by physical therapy students. Changes in balance were measured using Berg Balance Scale (BBS), Performance Oriented Mobility Assessment (POMA), and a post-test questionnaire addressing changes in daily activities.

OUTCOMES

Participants responses to the questionnaire and pretest/post-test differences in scores on BBS and POMA suggest trends towards improvement in balance.

RELEVANCE

A group balance skills class for individuals who had a stroke >6 months ago appears feasible. Further research is needed to determine the effectiveness of this class for improving functional balance and decreasing incidence of falls.

The effect of a multisensory exercise program on engagement, behavior, and selected physiological indexes in persons with dementia

A multisensory exercise approach that evokes the stimulation and use of various senses, such as combining physical and cognitive stimuli, can assist in the management of persons with Alzheimer's disease (AD). The objective of this study was to evaluate the outcomes of a multisensory exercise program on cognitive function (engagement), behavior (mood), and physiological indices (blood pressure, resting heart rate, and weight) in 13 nursing home residents diagnosed with moderate to severe AD. A one-group pretest/post-test, quasi-experimental design was used. The program combined a variety of sensory stimulations, integrating storytelling and imaging strategies. Results showed an improvement in resting heart rate, overall mood, and in engagement of physical activity. The findings suggest that a multisensory exercise approach can be beneficial for individuals with AD.

The use of federal and state databases to conduct health services research related to physical and occupational therapy

OBJECTIVE

To describe the characteristics of a number of secondary databases that have the potential to answer questions related to the use of, access to, and effectiveness of physical therapy (PT) and occupational therapy (OT).

DATA SOURCES

Federal and state databases maintained by the National Center for Health Statistics, the Agency for Healthcare Research and Quality, and the Centers for Medicare and Medicaid Services.

STUDY SELECTION

Databases, described above, that were identified as having potential for answering questions related to the use and effectiveness of PT and OT were examined.

DATA EXTRACTION

The databases were explored to determine if PT and OT had sufficient representation, and if so, to identify potential questions that could be answered by examining the databases in more detail. Some of the advantages, disadvantages, and methodologic issues of using the databases were identified.

DATA SYNTHESIS

Several databases are available that can be used by researchers to increase our understanding of the use of, access to, and/or effectiveness of PT and OT. Many of the databases are most suited for examining issues related to the use of and access to these services. A few of the databases can be used to examine the effectiveness of PT and OT.

CONCLUSION

Secondary data analyses are a particularly useful, cost-effective, and efficient means for preliminary exploration of topics that are not well understood, such as the use of, access to, and effectiveness of PT and OT.

Effect of a physical therapeutic intervention for balance problems in the elderly: a single-blind, randomized, controlled multicentre trial

OBJECTIVE

To establish the effect of a short, individualized exercise programme on balance dysfunction in the elderly.

DESIGN

A single-blind, randomized, controlled, multicentre trial.

SETTING

Physical and recreational therapy departments from two rehabilitation centres.

PARTICIPANTS

Ninety-four subjects of >75 years with functional balance problems living independently or in a residential care facility. Seventy-seven subjects completed the intervention period and four-week follow-up. At a one-year follow-up 49 subjects were evaluated on balance functioning.

INTERVENTIONS

Twelve sessions of an individualized balance training programme (experimental group) or 12 sessions of an individualized extra attention programme (control group) given in 4-6 weeks.

MAIN OUTCOME MEASURES

Berg Balance Scale and the Dynamic Gait Index to establish balance functioning, a visual analogue scale to establish fear of falling in daily life and the Hospital Anxiety Depression Scale to verify feelings of anxiety and depression.

RESULTS

Subjects in the experimental group improved significantly more on the Berg Balance Scale and the Dynamic Gait Index than those in the control group (p f 0.001, p f 0.001, respectively). However the effect disappeared at a one-year follow-up on the Berg Balance Scale. No prognostic factors could be identified to determine who would benefit most from the individualized exercise programme. Results on the other response variables revealed no effect of the intervention.

CONCLUSION

A short individualized exercise programme can improve functional balance in people aged 75 years and older. This improvement was maintained at least for one month but had worn off by one year.

Detecting change in patients with stroke using the Berg Balance Scale

The Berg Balance Scale (BBS) was designed to help determine change in functional standing balance over time. The purpose of this paper was to estimate the minimum detectable change score (MDC) using the standard error of measure (SEM), thereby providing a means to decide if genuine change had occurred. Calculation of the agreement regarding the presence of change as determined by the MDC and clinicians' perceptions was performed to give an indication of the validity of this criterion value. Forty-eight subjects who were receiving inpatient rehabilitation after stroke were assessed on consecutive days by two raters using the BBS. The MDC analysis suggests that a change of +/- 6 BBS points is necessary to be 90% confident of genuine change. Only 25/45 subjects showed agreement between the statistically derived presence of change and clinicians' perceptions of change. The lack of agreement may relate to the validity of the SEM/MDC methodology to determine the criterion BBS value, the heterogeneity of the subjects, or the use of clinician gestalt impressions of change.

Keeping the beat: use of rhythmic music during exercise activities for the elderly with dementia

Involving people with dementia in group exercise activities often presents a challenge. The effects of a recorded instrumental musical accompaniment was evaluated on participation in a series of 14 exercise activities with a group of nursing home residents with dementia. All exercise sessions, specifically designed by physical therapists for older adults, were lead by an activity aide and consisted of a series of seated exercises. Direct observations of resident behavior were conducted over a 25-week period in a reversal experimental design. Results showed increased levels of participation during the experimental condition observations where rhythmic music accompanied the exercise activities. The music intervention was most successful on those generally most willing to participate in social activities.

[Influence of a typical "posture-balance-motivity" motor practice on the postural capacities of elderly subjects]

OBJECTIVE

The object of this work was to observe the influence of the "Posture-Balance-Motivity" (PBM) activity on the total motivity in older adults.

SUBJECTS AND METHOD

After 12 weeks of practice, to observe the effects on the control of static postural sway by the intermediary of a force platform of 15 subjects (mean age 75.5, SD = 6.6).

RESULTS

Scores on "Posture", "Balance" and "Motivity" show respectively and significantly improvements. All scores of a clinical balance assessment scale, the POMA, have also improved. On the platform, parameters of spontaneous postural sway in the lateral (X) and antero-posterior (Y) axis have been evaluated with eyes open, eyes closed, on firm floor and foam floor condition. Values on the lateral axis did not show any significant decrease. But values on the antero-posterior axis showed a significant decrease for all modalities translating a better postural stability in this plan.

CONCLUSION

These first results show the advantages of a typical "PBM" activity.

Reliability of four simple, quantitative tests of balance and mobility in healthy elderly females

Four common tests of balance and mobility were administered to 45 healthy women, aged 55-71 years: Sharpened Romberg (also defined as tandem stance), eyes open and closed; One-Legged Stance Test, eyes open and closed; Functional Reach; and Sit-To-Stand test. Two independent observers scored the tests, which were performed on two successive days. Inter-rater (IRR) and test-retest reliability (TRR) were good. Across the six different tests, Intraclass Correlation Coefficients ranged from 0.95 to 0.99 for scoring consistency between rates, and from 0.73 to 0.93 within raters. This is in line with previous findings based on similar subjects and similar, though not identical, testing procedures. Intercorrelations between the scores were moderate: r coefficients ranged 0.40-0.66. The results suggest that this simple test battery provides reliable scores, and that the different tests relate to a homogeneous construct, while not being redundant. It thus seems worthwhile to further investigate whether they represent and measure a unidimensional domain, rather than conceptually different dimensions, in view of achieving a unique measure of balance performance.

Interrater reliability of the Tinetti Balance Scores in novice and experienced physical therapy clinicians

OBJECTIVE

To examine interrater agreement of scores by physical therapy novices and experienced clinicians on videotaped and live performances of the balance portion of Tinetti's Performance Oriented Mobility Assessment (BPOMA).

DESIGN

A reliability design was used to assess the interrater agreement and consistency of the BPOMA scores in an elderly population.

SETTING

General community hospital and skilled nursing facility.

PATIENTS

Twenty-six residents of a skilled nursing home, ranging in age from 66 to 99 yrs (mean = 80.4, SD = 6.8), participated in Phase 1. Twenty-four hospital inpatients and five residents of a skilled nursing home, ranging in age from 60 to 92 yrs (mean = 74.7, SD = 7.9), participated in Phase 2. RATERS: Three student physical therapists scored the patients in Phase 1. One student was designated the administrating rater (AR). The AR instructed, guarded, and scored the subjects. The other two students were the observing raters (ORs), whose role was to observe and score the subject's performances. Nine physical therapy clinicians, ranging from 0 to 6 years of experience, rated subjects in Phase 2.

MAIN OUTCOME MEASURES

Consistency and agreement of BPOMA scores were compared between clinicians with varying levels of experience. In Phase I, BPOMA was scored on-site by three student physical therapists. In Phase 2, videotaped performances were scored by five physical therapists, one physical therapist assistant, and three student physical therapists.

RESULTS

Phase 1 demonstrated fair to excellent kappa coefficients (.40-1.00) in all maneuvers across all raters. The ORs had higher agreement compared with the AR, ranging from good to excellent (.75-1.00). Phase 2 demonstrated fair to good kappa coefficients (.40-.75) in 5 of 8 maneuvers across all nine raters. When comparing proportion of observed agreement to evaluate the years of experience on rater agreement, there was no significant difference between clinician groups.

CONCLUSIONS

Fair to good reliability of BPOMA scores occurred across many rates of varied experience with a small amount of training.