Back to Basics for Balance and Gait

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Achieve more with less while fine-tuning your fall prevention approach

The “Silver Tsunami” is approaching, and therapists need to be prepared. As the baby boomer generation enters retirement age and the medical system, therapists must ready themselves for a unique set of standards.

Cookie-cutter protocols simply aren’t acceptable any longer. Boomers want customized programs and more personalized care; this is the trend.

According to the National Council on Aging, 25% of the population over age 65 falls each year. As the population ages, this number rises. Therapists in skilled nursing facilities must fine-tune their approach to fall prevention, thereby streamlining their balance and gait training techniques.

At Shuksan Healthcare Center, a 52-bed short-term rehabilitation and skilled nursing facility in Bellingham, Wash., we are seeing the trend with growing certainty. While our patients share the goals of improving function and returning home as soon as possible, our Older woman playing piano with physical therapistapproach to each patient is unique. Not only do patients appreciate this personalized approach, it’s quickly becoming necessary due to fiscal and time restrictions being placed on therapists.

How can we satisfy the patient, the doctors and the insurance companies? The current trend is personalizing care to achieve outcomes more quickly by addressing patients’ deficits. The constraints we must work within include reimbursement and length-of-stay restrictions, along with the pressing initiative to reduce hospital readmissions.

These require us to be as efficient as possible with each treatment. We do this by triaging the content of our care plan, performing exercises that combine multiple muscle groups, and focusing on function and safety.

Back to Basics

Our team begins with a musculoskeletal evaluation. This provides objective information of weak muscle groups and range of motion that is lacking.

In general, the most important muscle groups to strengthen for functional balance are the dorsiflexors, knee extensors, hip extensors and hip abductors. Conversely, the most common muscles that require stretching are the plantarflexors, knee flexors and hip flexors. When these muscle groups are appropriately balanced, an individual’s ability to perform safe functional mobility is improved.

The cascade of problems caused by weak or tight muscles is inevitable, and it is our specialty as physical therapy professionals to identify and correct these imbalances. Tight plantarflexors or weak dorsiflexors put a patient at risk for tripping over their toes while walking.

The same muscle asymmetry also causes impaired balance in standing when hyperextension of the knee causes flexion at the hips to maintain a person’s center of gravity over their base of support. Functionally, we see this in people having difficulty bringing their feet underneath their chair when preparing to stand from a sitting position, which increases their risk for falls during transfers.

Older woman decorating Christmas treeDon’t chase the symptoms; address the root of the problem to make a difference in creating more timely outcomes. Specific exercises for balance training should be very individualized and challenge a patient a bit beyond the current comfort level. In general, you can challenge a patient by progressing to a narrower base of support, changing the stability of the surface on which a patient stands, and decreasing feedback from their environment. To add a challenge to any of these stages, add upper-extremity activity to further challenge balance.

It’s not outside our scope to screen for visual deficits and to recommend a medication review when we feel it’s indicated. As the healthcare professionals patients spend the most time with, we can draw attention to issues that may otherwise be overlooked, and these factors can have a big effect on balance and safety.

What does this look like at a skilled nursing facility? Meet our former professional accordion player Ms. June. She came to us with a left humeral fracture after a fall at home. Her physicians expected us to rehabilitate her left arm, but we knew it was equally important to improve her balance and help prevent future falls.

We incorporated traditional treatment strategies to improve function in her arm, but discovered that she was most receptive to therapy while playing the piano, dancing and singing. While she played the piano in standing, we stabilized her proximal humerus as she used both hands to charm us with her rendition of “That’s My Baby.”

We asked her to vary her foot position to engage functional muscle groups as she naturally swayed to the music. Added benefits included resolving the swelling in Ms. June’s left hand and forearm, along with improved morale among nearby patients and staff.

Let’s get back to the original question of how to make everyone happy. Insurance companies require standardized test scores for balance to justify continued payment for therapy, and we use these scores to justify the impact we have on outcomes. They are also a good tool to see where our patients begin to falter in their abilities, which can show us where to begin in balance training exercises.

The score itself will not reveal the whole picture. You must know where to intervene based on what you see in your functional evaluation to achieve the best outcomes.

Not Just Walking a Patient

Effective balance training carries over to improving a patient’s gait. Instructing patients to normalize their gait pattern can be initiated in parallel bars utilizing demonstration, a full-length mirror and tactile cues, and facilitation from the therapist.

It’s important however to get into the hallway as soon as possible to practice the rhythm of gait that can only come with repetition. Therapists should prevent improper gait patterns from becoming ingrained, but also refrain from becoming overwhelming with corrections. Using the right verbal and tactile cues at the right moment can be the most important thing to recognize. Repetition is key.

Meet our gracious resident Ms. Ardis. She came to us with a periprosthetic femur fracture after eight weeks of being non-weight bearing. By this time in her recovery, she’d been compensating for so long that she was now hesitant and fearful to weight-bear on her affected leg.

We practiced weight-shifting and walking in parallel bars, but Ms. Ardis continued to off-load onto her arms. We quickly realized we’d need to be creative to diffuse her anxiety. One of her favorite activities was helping us decorate for the holidays. We would work on reaching, weight-shifting and building her confidence, all of which improved her balance and carried over to normalize her gait.

Individualized Care for Best Outcomes

The current challenge of care in skilled nursing facilities is balancing outcomes, dealing with insurance restrictions and preventing hospital readmissions. No matter their diagnosis, patients want to walk and not fall.

We must go back to the basics and evaluate each patient’s needs. It’s not a one-size-fits-all package any longer. Individualizing patient care and working with them toward reaching their goals faster leads to better outcomes, along with happier, safer, more balanced patients. Why not have a little fun while you’re at it?

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About Author

Jennifer Bauer, MSPT

Jennifer Bauer is lead physical therapist at Shuksan Healthcare Center, Bellingham, Wash.

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