Focal Physiotherapy

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Episode Transcript

Hi, thanks for joining us with the Focal Allied Health’s Podcast. This is a podcast for practitioners who are looking to improve their clinical knowledge and skills. And this is our first episode of this brand new podcast so I’m sure it’s going to and develop and so forth as we move along. We will be having a section on our website which will be listing these podcasts so be sure to pop along and leave comments on the episodes, et cetera. I’d love to get your input, your feedback, et cetera on them, and give us some information what different topics that you would like us to cover. Also, any thoughts that you’ve got with the topics that we may raise in the episodes, et cetera. Okay.

So what we’re going to do in this first episode is that we’re going to be discussing falls risks. Now, clearly this is a huge topic, and we’re only going to be able to address a small part of that today. However, is a very important topic, and it’s one which particularly for older adults is a very pressing and timely thing that needs to be looked at.

One of the things that makes it such an important thing to address is that there’s a very high risk of falls, or high rate of falls in older adults. So once people get over the age of 60, 65 the rate of falls increases to about 1:3 per year, which is quite high. It’s 33% of people are going to fall in a given year. And the problem with that is that there is a very real risk of injury and death occurring when people fall. And as a consequence of that, there’s a lot of costs associated with that for the healthcare system. There’s also a lot of cost associated with that for individuals, et cetera. And so falls are something that we very much need to address in our older population.

Now, one of the real issues, one of the additional issues is that when people suffer a fall as an older adult it’s frequently associated with loss of independence. Now, the way that this works is that quite often if people fall they start to become quite anxious and very fearful quite often about leaving the house, and going out, and engaging in public, and so forth. So, as a consequence they can become much more isolated. They can become cut off from the rest of society, and with all that loss of independence that comes with it. Associated with that you will often get anxiety issues and depression that develops as well. We are looking not only just at the physical aspect of falls, but we are looking at the implications to the individual from a psychological perspective, and issues around mental health, and independence, and ability to engage in the fun activities of life, to get some juice out of life and make life worth living for these older adults. So, this is an important thing.

The other aspect is that as people fall there is an increased chance that they’re going to move into aged care. Now, the problem with that is, apart from the cost aspect, is that this will often lead to further losses of independence for the individual. And rather depressingly, the falls risk actually usually increases further when people get into aged care. So you’re looking at it increases to 1:2 people in a year will fall when they get into aged care.

Now there’s many factors associated with that. Some of these are things like the muscle deconditioning that tends to occur within environments like that. Quite often people aren’t… Either they’re not encouraged to become more active and maintain their independence, or they are encouraged, but they don’t have the motivation to do so. And these facilities quite often don’t have the staffing requirements that could be going along and motivating each individual person, not a one- on-one basis, et cetera. So there’s all sorts of factors at play there. So, clearly it makes sense to try and actually stop the individual getting to the situation where they’re going to end up in aged care. And there’s thankfully quite a number of things that we can actually do to make sure that that is the case.

Now, when you’re looking at falls risk, generally we categorise three groups of factors that can predispose somebody to having a fall. Now, one of these groups is environmental factors. Another one of them is behavioural factors. And another one is what we call intrinsic factors.

Now, environmental factors are things like falls risk aspects around the house, for example. So things like loose rugs in the house, electrical cables that might be there for people to trip on, poor steps, or uneven steps, or uneven pathways, et cetera that pose trip hazards in the garden, et cetera. So there’s all sorts of factors that people can look at to try and reduce the environmental aspect, and there’s many, many environmental risk factor checklists which are available. You could just do a Google for falls risk checklists and quite often you’ll come up with all sorts of different lists that you can use, and that you can give to your patients or give to their kids or whatever. And they can then go round and audit their home, or you may well even decide that you want to offer that service to your patients where you can go round to their home and evaluate their falls risks and so forth. Okay.

So, with those environmental factors are a very important one and they have to be dealt with because it clearly makes no sense to have dodgy rugs lying around on the floor that somebody’s going to trip on. You can address all sorts of other aspects, but if they’ve got factors like that going on then it’s just going to predispose them to unnecessary risk.

Now, another factor, as I said, is behavioural aspects. Now, people need to be counselled not to take risks. It’s natural when you get older to want to try and maintain your independence. That’s almost a given. But what can happen is that people can take risks which are not proportional to their abilities, so to be trying to do things that they were able to do maybe 20 years ago is silly. Climbing up things like ladders, for example, using things like chairs to climb up to high cupboards as opposed to using a nice stable step ladder, or even better, maybe not even having high cupboards altogether so that there’s no temptation to try and climb up to reach those high cupboards. Things like walking dogs. You sometimes see older people walking dogs and the dogs are almost far too strong for that older adult. And if the dog cleared off, saw a cat or something like that and ran off, they may well pull the person over. You’ll sometimes see people getting dog leads caught up around their legs, and those sort of trip hazards, et cetera.

So there’s a wide variety of things which can impact upon your patient’s fall risk that are behaviour related. And so, one of the things that you are going to need to do as a healthcare professional is that you’re actually going to need to counsel your patients on those, and talk about some of the things that they do, and raise some of those topics with them, and try and work out what they can do to actually try and reduce the falls risk through behavioural modification. Okay. So that’s something that definitely needs to be done as well.

Now, the last group of factors is what is often referred to as intrinsic factors. And to me, this is actually quite the exciting part for us, particularly those of you that are listening that are physical therapy type based. So whether that be a physiotherapist, or a chiropractor, or an osteopath, or something like that, these are the ones that in many ways we can actually do some work with, or if you can identify them, factors such as vision or whatever, you can refer appropriately to try and get something worked out, and so on.

So some of these intrinsic factors, as like I just said, vision is an important one so you need to make sure that patients have good visual acuity. So obviously things such as macular degeneration, cataracts, et cetera, in older populations are things that can obviously impair vision. So if they have those then obviously they need to be referred as appropriate onto practitioners to deal with that. You can also look at things like glasses. So [silence].

You may well find that they’re actually not aware of trip hazards in the environment because of the blurring effect that these multifocal glasses are potentially going to give them. So if they’re walking along an uneven pass, or there may be tree roots in a pass, or maybe some kids left a stick on the ground or something and grandma’s walking along and doesn’t see it because she’s got her multifocals on, that is a big thing where they can end up unfortunately making contact with the ground rather forcefully as a consequence of their vision.

Another thing that you can look at is visual contrast sensitivity. So what that becomes relevant for is things like seeing steps or seeing other trip hazards. If they’re low contrast trip hazards then you may actually have the situation where the older adult just will not see them, and therefore they’re more likely to fall over.

Now, the Neura Group out of Sydney have produced an app which allows you to assess visual contrast quite easily using an iPad. I think it’s only 50 bucks, or something like that, so it’s really quite cheap to bring into your clinic, and it will only take you a minute or two to evaluate that on your patients. And that can be something that you can identify as being an issue, and then you can refer to optometrists, et cetera, for further evaluation as needed.

Now, another thing you can actually do with vision is you can look at motion sensitivity. So the older adults will quite often be motion sensitive. One of the things that we know as they get older is that quite often, as they lose proprioceptive acuity and they also lose vestibular acuity, they will start to become very vision dominant in their attempts to maintain balance. And then when they become visual dominant, when they have visual field mismatches, such as, for example, standing next to a bus. You’ve probably all experienced this, that you stand next door bus and the bus starts driving off and you feel like you’re falling over because the bus all of a sudden starts to move. I’m sure you can imagine what I’m describing. If older adults have that visual field motion sensitivity it can compromise their balance and increase their risk of falling.

Now, one of the ways that you can do this is that you can present optokinetic stimulation to them, again using an iPad. And whilst it’s not the same as doing the full field optokinetic stimulation that some testing centres will do, for a clinic based situation that may well actually be quite satisfactory. So, that’s another thing that you can do with your older adults.

Things such as muscle strength obviously will affect balance, and therefore falls risk. So things like explosive power. Things such as just outright muscle weakness will compromise muscle strengths, and therefore the ability to correct from a fall quite often, or some sort of balance perturbation. So, testing your patient’s muscle strength and maybe even explosive muscle power. So things like vertical jump tests and so forth can give you a window to muscle strengths as well.

And one thing that I’m particularly interested in is looking at things like vibration sensitivity and touch sensitivity. So you can do things like just with a tuning fork you can assess vibration sensitivity. That’s very easily done within the clinic. And similarly, you can do touch sensitivity. So you can buy micro filaments which will do certain levels of light touch sensitivity. So usually 10 grammes of touch sensitivity is used, though I would potentially argue that we should actually be testing at a lower threshold in that even around four grammes or so to maybe potentially address earlier changes as part of our assessment of these patients.

And you can also do things like assess proprioceptive acuity as well. So one of the ways that we do this in our practise is that we will get the patient with their eyes closed. We will position one ankle in a particular degree of dorsi or plantar flexion, and then using an iPhone you can just use the inclinometers that you get on the iPhones, and you can measure the angle that that foot is sitting at. And then you get the patient and say to them, “Look, can you reproduce that angle in the other foot?” And you can use the iPhone to compare side to side and check the angle of inclination and so forth. So, it’s very easy to do with very low tech options within the practise. You don’t need to go out and spend thousands and thousands of dollars on high tech testing equipment to be able to do that.

Similarly, the balance evaluation scale is another way that you can actually assess balance within the practise, and they can give you objective measurements. Now, one of the things that we like to use when we’re assessing balance with our older adults, or in fact with all age groups, is stabilometry or posturography. Now stabilometry is something that you’re probably familiar with, even if you haven’t come across the term before. Most people will have used a Nintendo Wii balance board. And these balance boards basically use strain gauges, or there’s a number of ways that they do it depending on the technology that they’re using. But basically what is happening is that the board uses forces, or basically the forces generated by a person standing on the board, to measure what is known as the centre of pressure. Okay. And so that’s what this stabilometry is.

Now, the Wii balance board is, as I said, a very commonly available measure of that, and which has been shown to have quite good diagnostic accuracy. There’s certainly no harm in using the Wii balance board if you are doing balance assessments, particularly on a screening level. They’re quite good. The evidence suggests that that’s the case. There’s obviously much more high tech versions, things like Kistler plates, Bertec plates, Vestibular Technologies plates. There’s a wide variety of plates out there that you can get these days that you can use to actually quantify balance.

Now, what these plates do is that they measure the centre of gravity. Well, basically they say that they’re measuring the person’s centre of gravity, but in actual fact what’s happening is that they’re measuring the centre of pressure, which is a measurement which is extrapolated from the movements of the patient’s centre of gravity. And so basically, it’s the ground reaction force to the centre of force that is being applied by the person standing on the plate. Okay. Now hopefully that makes sense, but don’t get too hung up on it. And what you can then do is that you can actually do things like measure the speed of the movement of somebody’s centre of pressure. You can look at the root means square of deviations of the centre of pressure from the central or the mean measure of centre of pressure. So basically, you look at well, how far does the person sway? You look at how fast do they sway?

You can also do what’s called calculating a sway ellipse, which is predicted to contain 95% of the centre of pressure measurements. And so that can basically give you an area that you can then compare in pre and post testing and so forth. And these deviations, and velocities, and sway areas, and so forth, give you a quantification of a person’s balance. And these measures tend to increase as balance gets worse. So what we want to try and do is we want to try and do interventions with our patients to try and reduce the size or the magnitude of these sway measures. Okay.

So, that’s what I wanted to touch on this week within this podcast. As I said, this is our first episode. What we’re going to do next episode is I want to talk about a study which has actually been using centre of pressure from sway speed. And they’re looking at things like complexity of sway and how that correlates with balance and so forth, and some very interesting research about using sub sensory vibration to actually improve sway in older adults. And some really interesting stuff coming out around that where you can look at using vibration interventions to try and improve balance parameters.

So, we’ve touched on a lot here. We’ve talked about how there’s these obviously risk factors for older adults and how having these falls is really not a good thing for the older adults, how that increases their chances of moving into aged care, and mortality and so forth. We looked at environmental behavioural and intrinsic risk factors and how you might go about assessing some of those intrinsic risk factors. And then at the end here, obviously we’ve touched on using stabilometry to measure a person’s balance, using measures such as speed of sway, magnitude of sway, an area covered by sway and so forth.

So, hopefully you found that interesting. It’s something that we want to talk more about as we move along. I’d love to cover other topics, particularly to do with aspects such as management of neurological conditions in older adults. Or we’ve got some really great information I want to talk about, concussion management and so forth, as we move further along. We do a lot of vestibular rehabilitation and so forth in our clinics as well so I’m hoping that you’re actually going to find these very interesting. Let me know what you think, I’m very keen to know.

Okay. So thanks for listening to our podcast. If you are an Allied Health practitioner consider working for us at Focal Allied Health. New graduates and experienced practitioners are welcome to apply. Head across to focalhealth.com.au/careers for current positions. Alternatively, if you are a practice owner looking to exit your practice, contact us today about making your practice a part of our team. Head along to focalhealth.com.au/join.