Transcript 3-Assessment_pre-exercise_casestudy_practi

Detection and Assessment:
Theory
- Finding fallers…in different settings:
- Pre-exercise assessment
- Health, Function and Motivation
- Ongoing assessment
- Triggers for referral to medical setting
- Triggers for referral between exercise
settings
Specialist PSI Exercise Module
Targeting Intervention
Identify high risk from a general population
Identify what more in depth assessment is required
Identify modifiable risk factors for each individual
Target Intervention
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NICE Falls CG: “Safety net” service model
Specialist PSI Exercise Module
NICE Falls CG: specialist integrated service
model
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What tool or test ?
It needs to be:
 Reliable
same result in same person
over short intervals of time
 Consistent
same result whoever
assesses
 Valid
for the age and functional
capacity of the individual
Plus functional and understandable to the older person
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The role of pre-exercise assessment
• Assessment
– is the cornerstone of rehabilitation
– identifies health status (safety and
warning signs)
– identifies areas of limitation
(pre-exercise)
– influences subsequent
treatment/intervention (tailoring)
– gauges efficacy of treatment (ongoing)
Specialist PSI Exercise Module
Pre-exercise Assessment
• Assessment should be:
– what they can do and build upon …..NOT. ….
what they cannot do
– an education tool (fitness vs health symptoms)
– relevant (age, medical condition and functional capacity of
the participant)
Specialist PSI Exercise Module
TRIGGERS
Referral back to Rehab Exercise Setting
• Onto therapy setting (or stay within chair-based setting)
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cannot stand for more than 30 seconds without excessive sway
cannot transfer weight from one leg to another without concern
cannot take a step backwards unassisted
chronic or acute pain on walking
marked deformities, severe asymmetry, marked weakness
Functional Grid
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ticks mainly 6’s
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Ongoing Assessment
• ? Every 3 / 6 / 9 months or if participants health or functional
condition deteriorates
• Essential for
– updating health or functional status information
– assessing effectiveness of programming
– comparing goals with actual gains
– improving motivation
• Continually assess
– environment and safety
– ‘appearance’ of participants
– correct intensity (Borg)
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TRIGGERS
Ongoing assessment - 1
• Sudden onset of symptoms of illness
– Dizziness, inner ear infections, excessive tiredness, weight loss,
loss of appetite or shortness of breath, anxiety, unidentified or
uncontrolled pain
• Worsening of existing medical condition
– Frequency of transient ischaemic attacks increases, swelling of an
OA knee following the session or a longer than usual walk
• Onset of dizziness with current or new medications or concerns
about whether correct pills are being taken at the correct time or
dose
• Sudden onset of pain in joints
– Osteoarthritis of the knee, swollen joints, limping
Specialist PSI Exercise Module
TRIGGERS
Ongoing assessment - 2
•
Deterioration of functional capacity or balance
– Now needs walking aid, progressive difficulty with walking on the flat,
fatigues more quickly, transfers becoming difficult
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Increase in frequency of falls or increase in injury due to falls
– Starts to fall at home in repeat areas of the house or doing certain tasks,
can no longer rise from the floor, injuries not healing properly, arrives with a
black eye and has not been to see the GP after the last fall yet
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Distinct changes in vision
– Depth perception, missing steps, light-headedness on walking downstairs
with bifocals
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Distinct changes in hearing
– Wax removal, inner ear infection
Specialist PSI Exercise Module
The value of assessment
• You get to know your participants
• Good time to discuss exercise history, likes, dislikes
and perceptions of exercise and of falling
• You’re safe and so are they
• You know where to start and where to adapt
• You know if you are getting it right
• Funder’s know you are getting it right
• Participants feel informed
Specialist PSI Exercise Module
Case Study Guidelines
• Find a person at risk of falls or with a falls history that
would be able to join a PSI led class
• Perform functional assessments and do the health /
QoL / fear of falling questionnaires with them
• Write up – 1500 words
• Include tailor / adapt the FaME phases of training for
that individual
• Present the written case study on Day 6/7
• See Case Study Guidelines in your pack
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Practical / Case Study Guidelines
• Pre-exercise Assessment
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Readiness to exercise
Health
Falls Risk (FRAT)
Fracture Risk (Black)
Fear of Falling (FES-I )
Confidence in Maintaining Balance (ConFBal)
Health outcome (EQ-5D)
Functional Assessments - GRID
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Selection Criteria
-Is your participant at risk of falls?
Each individual should have one or more
of the following:
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Fear of falling
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Feeling unstable (balance problems)
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History of falls (injury or not)
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Low bone density (and/or family history
of osteoporotic fracture)
Specialist PSI Exercise Module
Readiness to Exercise
• Stage of Health Behaviour Change
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Considering
Preparing
Currently Active <6 Months
Regularly Active >6 Months
Relapse
Unknown
• Gauge from a conversation with them about
exercise history and current participation
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Health Assessment
Referred or self-referred
•
Health status must be checked with / acknowledged by
participants GP
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Complete a health questionnaire with them that will identify
their medical conditions and medications
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Use to ensure your know if someone has any conditions which
are contraindicated and need specific feedback from GP before
they can continue in the class
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A health questionnaire is in your case study pack but when you
qualify you may use one that has been developed by your
service.
Specialist PSI Exercise Module
Contraindications to the ‘Prehab’ Class
People with the
following:
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Uncontrolled angina
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Uncontrolled resting BP
> 180/100 mmHg
Significant drop in BP during
exercise
Uncontrolled tachycardia
> 100 bpm
Unstable or acute heart
failure
Uncontrolled acute systemic
illness
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Uncontrolled visual or
vestibular problems
Unable to maintain seated
upright position
Recent injurious fall
without attention
Impaired cognition
Place others and
themselves at risk
should not take part until their GP advises that their condition
permits safe participation
Specialist PSI Exercise Module
History of Fall
• Number in last 6 months
• Last one
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Location
Time
Doing what?
Reason?
Loss of consciousness? Or dizziness prior?
Any injury?
Could they get up again?
Did they see GP or go to Hospital?
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FRAT – Falls Risk Assessment
Tool
Multi - professional guidance for use by the primary health
care team, hospital staff, and social care workers
Is there a history of any fall in the previous year?
How assessed? Ask the person.
Is the patient / client on four or more medications per day?
How assessed? Identify number of prescribed medications.
Does the patient / client have a diagnosis of stroke or Parkinson's Disease?
How assessed? Ask the person.
Does the patient / client report any problems with their balance?
How assessed? Ask the person.
Is the patient/client unable to rise from a chair of knee height?
How assessed? Ask the person to stand up from a chair of knee height without using
their arms.
Specialist PSI Exercise Module
Risk of Fracture Tool
• Black 2001
– High risk Score 7-10
– Moderate risk Score 5-6
– To use in your case study
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Fear of Falling Scale – FES-I
• Long Version – 16 Qs
– Yardley et al. 2006
• Short Version – 7 Qs
– Kempen et al. 2008
– To be used for your case
study
– Scoring
• 7 (no concern about
falling) to
• 28 (severe concern
about falling).
ProFaNE recommended
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Confidence in Maintaining Balance
• Simpson et al. 2004
• 10 Qs
• Scoring
– 10 confident
– 30 unconfident
• Use for your case
study
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EQ-5D – heath outcome measure
• Page 1
So this
would
score as:
1,2,3,4,5
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EQ-5D
• Page 2
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Functional
assessment
No Limitation
Seated shoulder external
rotation flexibility
Can reach over their
shoulder to between
their shoulder blades
Denote L and R arm in box(es)
1
Seated shoulder internal
rotation flexibility
Can reach to behind
the back to touch
their shoulder blades
Denote L and R arm in box(es)
1
Seated hamstring flexibility
Able to reach to midcalf of the extended
leg
Denote L and R arm in box(es)
1
180 degree turn
Able to turn safely in
4 steps or less
Number of steps: ______
1
Functional Reach
Reaches greater than
35 cm
Use of walking aid? Cm:____
1
Timed Up and Go
Use of walking aid?
Time (seconds):_____
Able to rise from the
chair easily, walk
unaided, turn without
dizziness or
stumbling. Faster
than 8 seconds
1
Severe Limitation
Can reach to the
back of the neck
2
Can reach to
behind the back to
touch just below
the shoulder blades
2
Able to reach just
past knee of the
extended leg
2
Able to turn safely
in 6 steps or less
2
Reaches between
25 and 34 cm
2
Able to rise from
the chair without
arms, walk
unaided, turn
without stumbling.
Between 9 and 15
seconds
2
Can reach behind the
head to level of ears
3
L
Can reach behind to
mid-back level
3
L
Able to reach to knee
of the extended leg
3
Able to turn safely in
8 steps or less
3
Reaches between 16
and 24 cm
3
Difficulty on rising
from chair, walks
aided or unaided but
takes between 16 and
24 seconds
3
Can reach the top
of their head
4
R
Can reach behind
to waist level
4
R
Able to reach to
mid thigh of the
extended leg
4
Needs close
supervision and
verbal cueing for
safety. Takes 9-12
steps
4
Reaches between
10 and 15 cm
4
Difficulty on
rising from chair,
walks aided or
unaided but takes
between 25 and 40
seconds
4
Can reach above
shoulder level but
not touch the top of
their head
Unable
Unable to reach above
shoulder level without
pain or movement
limitation
5
6
Can reach behind to
buttock level
Unable to reach behind
their back, pain or
movement limitation
5
6
Able to reach to
knee but unable to
complete with
correct technique
5
LR
Needs assistance
from one person or
furniture to turn
5
Reaches less than
10 cm
5
Difficulty on rising
from chair, needs
walking aid,
unconfident or
dizzy on turning or takes over 40
seconds
5
Unable to reach
forward because of
pain, deformity or fear
of falling
6
Needs assistance from
two people to turn
6
Unable or afraid to
reach forward
6
Unable to rise from the
chair, walk or turn
without help
6
Specialist PSI Exercise Module
FLOW DIAGRAM FOR PROSPECTIVE PARTICIPANTS IN EXERCISE SESSIONS TO IMPROVE POSTURAL
STABILITY AND REDUCE FALLS AND INJURIES
Referrer
Selection
Criteria
Functional Assessment Grid
Exercise
Groups
Mostly ticks
SELF – REFERRED
1
2
DYNAMIC
‘PREHAB’
PSI
3
4
GP – PRIMARY
CARE
Those
meeting
inclusion
criteria
and
having
no
exclusion
criteria
5
6
PHYSIOTHERAPY REHABILITATION
SETTING
CHAIR –
BASED
(maybe PSI
led or chair
adaptations)
P
R
O
G
E
S
S
W
I
T
H
T
I
M
E
‘REHAB’ –
THERAPY
(one to one or
small group)
Specialist PSI Exercise Module
Final thoughts on case study
• You need to tailor the phases of the FaME programme to
your participants abilities
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Any limitations (adaptations)
Any confidence issues (buddying)
Are they particularly good at anything (so can progress faster)
Asymmetry (homework)
• In your judgement would they progress through any of the
phases faster/slower?
• Consider the main points of this individual you would want a
cover teacher to know?
– Medications
– Limitations
Specialist PSI Exercise Module