Transcript CeceliaGriffith_Using a Multidisciplinary Approach to Determine

Using a Multidisciplinary
Approach to Determine
Impairments in
Movement and Mobility
Dr. Cecelia Griffith, PT, DPT
[email protected]
What is the Multidisciplinary Team?
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Taber's Cyclopedic Medical Dictionary, 20th Edition
“Relating to multiple fields of study involved in
the care of patients. The term suggests that the
various disciplines are working in collaboration,
but in a parallel mode of interaction. Each
distinctive discipline is accountable and
responsible for its tasks and functions regarding
patient care.”
Importance of Multidisciplinary
Approach to Geriatric Care
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Patient-centered
Coordinated care: the right hand knows what
the left hand is doing
Holistic
Physiological
 Functional
 Emotional
 Spiritual
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Role of the Multidisciplinary Team in Assessment
and Treatment of Mobility and Balance
Bowel
&
Bladder
Neurological
Musculoskeletal
Vision
Cognitive
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Discipline
H&P
Organ
systems
Physician
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Nursing
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Occupational
Therapy
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Physical
Therapy
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Speech/
Language
Pathologist
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Psychologist
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Ophthalmologi
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Communication
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Selfcare
Education
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Understanding Balance
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Multi-system Function
Impacts all levels of mobility and function
Every patient is a balance patient
Dynamic Equilibrium
Sensory Organization
Motor Coordination
Determination
of Body Position
Choice of
Body Movement
Compare, Select
& Combine Senses
Select & Adjust
Muscle Contractile Patterns
Visual
System
Vestibular
System
SomatoSensation
Environmental
Interaction
Courtesy of Neurocom International
Ankle
Muscles
Thigh
Muscles
Trunk
Muscles
Generation of
Body Movement
The Need for Balance and Fall Prevention
Programs and Assessment.
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2029
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2003:
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1.8 million older adults injured from falls
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13,700 died of fall injuries
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Cost of falls ~ $43.8 billion by 2020
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Older population increasing faster than total population
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Total population increasing 1.2% per year
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65+ increasing 2.0% per year
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75+ increasing 2.7% per year
Demographics, Cont.
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Falls are leading cause of injury deaths
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Women are 67% more likely to fall
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Men are 49% more likely to die from falls
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Exercise decreases fall risk
Effects of Aging on Balance
Woollacott, MH and Shumway-Cook, A; Changes in posture control across
the life span--a systems approach.; Physical Therapy, 1990 Dec;70(12):799-807.
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Declining Vision
Sensory-neural Hearing Loss
Declining somatosensory input (proprioception)
Ankle dorsiflexor weakness
Temporal organization of postural muscle responses
changes
Assessment of Balance
Test
Purpose
Timed Up and Screening
Go (TUG)
Discipline(s) Patient Population
All
Geriatric
MEOW
Evaluation and Physician
Diagnosis
Geriatric
Berg Balance
Scale
Objective
evaluation
PT, OT
Frail elderly,
neurologically impaired,
low to mid-functioning
adults
Vision/VOR
Objective
evaluation
MD/DO,
PT, OT
All
Assessment of Balance, Cont.
Test
Purpose
Discipline(s) Patient Population
Dynamic Gait Objective
Index (DGI) evaluation
PT, OT
All, medium to higher
functioning adults
Functional
Gait
Assessment
(FGA)
Objective
evaluation
PT
Adults with vestibular
impairment; has a
format that combines
with DGI
Tinneti
(POMA)
screening
MD/DO,
PT, OT
Frail elderly, low to midfunctioning adults
Multiple Task
Test (MTT)
Objective
evaluation
PT, OT
Parkinson’s Disease
“MEOW”
Nnodim, JO, Alexander, MB, Assessing falls in older adults: a comprehensive fall evaluation
to reduce fall risk in older adults; Geriatrics. 2005 Oct;60(10):24-8
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Environmental
Eyes
Ethanol
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Orthostatic hypotension
OUCH! (pain)
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Weakness in the lower extremities
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Multifactorial
Medical (Acute)
Medical (chronic)
Medicines
Mental
Maladaptive assistive devices
Multifocal lens
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Multifactorial, i.e., multi-system problem
Medical (Acute): rule out acute etiologies
Medical (chronic): evaluate for exacerbation of chronic
conditions
Medicines: at risk if on 3 or more medications,
especially if for blood pressure or depression
Mental: evaluate for depression and cognitive
impairments
Maladaptive assistive devices: are they using the
appropriate device and is fit properly to them?
Multifocal lens: evaluate for visual impairments and
effects on balance of bifocals or trifocals
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Environmental: Home safety
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Eyes (and ears)
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Throw rugs
Night lights
Clutter
Trip hazards
stairs
Oculomotor exam
Nystagmus
DVA
VOR
Ethanol
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Orthostatic hypotension
Office testing
 Tilt-table test
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OUCH! (pain)
Pain medications
 Limiting activity due to pain
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Weakness in Lower Extremities
Manual Muscle Testing
 Effect of Statin Drugs
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Search Pub Med: “myopathy AND statins”
 Rhabdomyolysis and Type 2 Muscle atrophy
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“Sit to Stand Test”
 “Stair Test”
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Berg Balance Scale
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“Gold Standard” developed in 1988 by K. Berg
at McGill University and published in 1992.
14 items, scored on 0-5 scale
0-20 = High risk of falling
21-40 = Moderate risk of falling
41-56 = Low risk of falling
Berg et al; Clinical and Laboratory Measures of Postural Balance in an Elderly Population;
Archives of Physical Medicine and Rehabilitation, 1992 Nov;73(11):1073-80
Berg Balance Scale, Cont.
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Below 20: possible need for wheelchair
assessment.
20-35: Generally indicates need for a walker
35-45: Generally indicates need for a cane
Over 45, Generally safe without an adaptive
device in most settings
Quad cane vs. Single point cane
TUG
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Use as a screening measure to determine need for further assessment (Berg or
other measure).
Place a tape/line 3 meters ( 10 feet) from the front of a stable chair with
arms. Have the patient sit in the chair. Time the patient from the time you
say “go” until they return to sitting in the chair. Stop timing when the
patient’s buttocks hit the chair bottom. The chair should be firm with arms
to push from if necessary.
Instruct the Patient to stand when you say “go” walk forward at their normal
pace to the mark, turn and walk back to the chair and be seated. Let them
know they are being timed.
Scoring:
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(3) < 11.5 seconds without evidence of imbalance.
(2) > 11.5 seconds or has evidence of imbalance
(1) > 11.5 seconds with (and) evidence of imbalance
(0) Unable to perform without assistance
Additional Tests to Consider
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Dynamic Gait Index
Tinetti
Future Development
Functional Gait Assessment
 Multiple Tasks Test
 Tests specific to particular patient populations
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Questions?
Bibliography
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Berg et al (1992). Clinical and laboratory measures of postural balance in an elderly
population. Archives of Physical Medicine and Rehabilitation, 73(11):1073-80.
Nnodim, JO. Alexander, MB. (2005) Assessing falls in older adults: a comprehensive
fall evaluation to reduce fall risk in older adults. Geriatrics,60(10):24-8
Woollacott, MH. Shumway-Cook, A. (1990) Changes in posture control across the life
span--a systems approach. Physical Therapy, 70(12):799-807.
Woollacott, M. Inglin, B. Manchester, D. (1988) Response preparation and postural
control. Neuromuscular changes in the older adult. Annals of the New York Academy of
Sciences, 515:42-53.
Shumway-Cook, A. Brauer, S. Woollacott, M. (2000) Predicting the probability for falls
in community-dwelling older adults using the Timed Up & Go Test. Physical Therapy,
80(9):896-903.
Bibliography
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Southard, V. Dave, M. Davis, MG. Blanco, J. Hofferber, A. (2005) The
Multiple Tasks Test as a predictor of falls in older adults. Gait and Posture, 22:
351-55.
Boulgarides, LK. McGinty, SM. Willett, JA. Barnes, CW. (2003) Use of
Clinical and Impairment-Based Tests to Predict Falls by Community-Dwelling
Older Adults. Physical Therapy, 83: 328-39.
Steffen, TM. Hacker, TA. Mollinger, L. (2002) Age- and Gender-Related Test
Performance in Community-Dwelling Elderly People: Six-Minute Walk Test,
Berg Balance Scale, Timed Up and Go Test, and Gait Speeds. Physical Therapy,
82: 128-37.
Lajoie, Y. Girard, A. Guay, M. (2002) Comparison of the reaction time, the
Berg Scale and the ABC in non-fallers and fallers. Archives of Gerontology and
Geriatrics, 35: 215-25.
Whitney, S. Wrisley, D. Furman, J. (2003) Concurrent validity of the Berg
Balance Scale and the Dynamic Gait Index in people with vestibular
dysfunction. Physiotherapy Research International, 8: 178-86.
Bibliography
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Lajoie, Y. Gallagher, SP. (2004) Predicting falls within the elderly community:
comparison of postural sway, reaction time, the Berg balance scale and the
Activities-specific Balance Confidence (ABC) scale for comparing fallers and
non-fallers. Archives of Gerontology and Geriatrics, 38: 11-26.
Hatch, J. Gill-Body, KM. Portney, LG. (2003) Determinants of Balance
Confidence in Community-Dwelling Elderly People. Physical Therapy, 83: 107279.
Whitehead, C. Miller, M. Crotty, M. (2003) Falls in community-dwelling older
persons following hip fracture: impact on self-efficacy, balance and handicap.
Clinical Rehabilitation,17: 899-906.
Bloem, BR. Valkenburg, VV. Slabbekoorn, M. Willemsen, MD. (2001) The
Multiple Tasks Tests Development and normal strategies. Gait and Posture, 14:
191-202.