Progression of Tasks: Modification of Task or Environment *Summarized

Modification of task or Environment are needed by geriatric patients to improve adaptive locomotion

· ​Enhancing adaptive locomotion in structuring rehabilitation programs through a framework as suggested by Frank and
Patla are composed of reactive control, predictive control, and anticipatory control.

· Vision acts as a crucial modality in community mobility and training through tasks

· Training activities are composed of:

· step-by-step modifications to hitting targets and avoiding obstacles of varying heights

· ambulating while carrying an object that obscures view of legs

· training under challenging lighting conditions

· scanning the environment prior to and during locomotion.

· ​For Obstacle courses: ​.As physical therapists we can provide this intervention to address our patients in improving
their mobility. Obstacles may include, stepping up and down on a stool, walking on different surfaces, or walking
around cones.

· ​For Directional Training​: As physical therapists, we can train our patients in full utilization in improving their ability
such as increasing speed in backward walking

· ​Dual Tasking​: In this aspect, the patient’s full attention should be directed in controlling their gait and the fall risk.
Since adults may have difficulty isolating their task with required attention as compared to younger adults.
HOSPICE CARE

-​ d​ erives from the Latin term ​hospitum​, which originally described a place of shelter for sick and weary travelers.

-​ H
​ ospice care is mostly aimed at patients who have been diagnosed with a terminal illness

-​ A
​ imed at providing patients with a dignified pain-free death

PALLIATIVE CARE

- d​ efined by WHO, palliative care is an approach in improving the quality of life for both the patients and families
who are facing life-threatening illness.

-​ T
​ his includes patients who may be at any stage of their disease process, who may also be seeking curative treatment.

-​ P​ alliative care helps maintain quality of life and reduce illness symptoms
Core and Balance Exercises

Balance exercises for seniors- an essential part of an osteoporosis exercise program.

They should include fall prevention exercises that reduce your risk of a fall. But even if
you have not achieved that senior status, balance exercises for seniors will keep you
active and mobile as you age and more confident.

BALANCE
1. TRUE- Balance exercises for seniors are an essential part of an osteoporosis
exercise program.
2. FALSE- Your ability to keep your balance does not change over time without you
noticing it.
3. FALSE- Good balance can result in falls, which in turn can lead to serious injury
or he complete loss of mobility.

CORE
1. TRUE- Core strengthening is important for everything from increased mobility
and better body strength to reduced pain levels and improved balance.
2. TRUE- Core program uses plank and side plank poses to improve posture and
balance, enhance performance and strengthen from head to toe.
3. FALSE- Core strength training to a regular exercise routine is not a great way to
become stronger and more confident and have a better quality of life.

ALBANIA, SOLAYAO, TICORDA

14 EXERCISES SENIORS CAN DO TO IMPROVE THEIR BALANCE

Exercise 1: Single Limb Stance

Exercise 2: Walking Heel to Toe

Exercise 3: Rock the Boat

ALBANIA, SOLAYAO, TICORDA

Exercise 4: Clock Reach

Exercise 5: Back Leg Raises

Exercise 6: Single Limb Stance with Arm

ALBANIA, SOLAYAO, TICORDA

Exercise 7: Side Leg Raise

Exercise 8: Balancing Wand

Exercise 9: Wall Push-ups

ALBANIA, SOLAYAO, TICORDA

Exercise 10: Marching in Place

Exercise 11: Toe Lifts

Exercise 12: Shoulder Rolls

ALBANIA, SOLAYAO, TICORDA

Exercise 13: Hand and Finger Exercises

Exercise 14: Calf Stretches

REFERENCES:

https://melioguide.com/health-guides/balance-exercises-for-seniors/

https://www.lifeline.ca/en/resources/14-exercises-for-seniors-to-improve-strength-and-balance/

ALBANIA, SOLAYAO, TICORDA

Gait Characteristics: Typical Changes with Aging

● Aging is accompanied by multiple changes in sensory, motor, and central nervous

system integration of systems that interact to bring about predictable changes in gait
performance.
● Common sensory (affector system) changes include ​decreased acuity of visual
and auditory systems, and decreased somatosensory and proprioceptive
status​. These changes can lead to inaccurate appraisal of environmental demands
or erroneous self assessment of positioning and/or movement.
● Common motor (effector system) changes include ​decreased motor neuron
conduction velocity, periarticular connective tissue stiffness, and decrease in
numbers of motor fibers​ resulting in limitations in ROM and muscle strength.
● Central nervous system integrative changes might include loss of brain cells and
altered level of neurotransmitter production resulting in slowed reaction time and
decreased facility of movement presenting as motor control deficits.
● Alignment and arthrokinematic changes can result from or be caused by changes in
strength and flexibility with aging. It is difficult to know which came first—the gait
deviation or the ROM limitation—but they are clearly interrelated.
 Stress incontinence
If urine leaks out when you jump, cough, or laugh, you may have stress incontinence. Any
physical exertion that increases abdominal pressure also puts pressure on the bladder. The
word "stress" actually refers to the physical strain associated with leakage. Although it can be
emotionally distressing, the condition has nothing to do with emotion. Often only a small amount
of urine leaks out. In more severe cases, the pressure of a full bladder overcomes the body's
ability to hold in urine. The leakage occurs even though the bladder muscles are not contracting
and you don't feel the urge to urinate.

Stress incontinence occurs when the urethral sphincter, the pelvic floor muscles, or both these
structures have been weakened or damaged and cannot dependably hold in urine. Stress
incontinence is divided into two subtypes. In urethral hypermobility, the bladder and urethra shift
downward when abdominal pressure rises, and there is no hammock-like support for the urethra
to be compressed against to keep it closed. In intrinsic sphincter deficiency, problems in the
urinary sphincter interfere with full closure or allow the sphincter to pop open under pressure.
Many experts believe that women who have delivered vaginally are most likely to develop stress
incontinence because giving birth has stretched and possibly damaged the pelvic floor muscles
and nerves. Generally, the larger the baby, the longer the labor, the older the mother, and the
greater the number of births, the more likely that incontinence will result.

Age is likewise a factor in stress incontinence. As a woman gets older, the muscles in her pelvic
floor and urethra weaken, and it takes less pressure for the urethra to open and allow leakage.
Estrogen can also play some role, although it is not clear how much. Many women do not
experience symptoms until after menopause.

In men, the most frequent cause of stress incontinence is urinary sphincter damage sustained
through prostate surgery or a pelvic fracture.

Lung conditions that cause frequent coughing, such as emphysema and cystic fibrosis, can also
contribute to stress incontinence in both men and women.

Urge incontinence
If you feel a strong urge to urinate even when your bladder isn't full, your incontinence might be
related to overactive bladder, sometimes called urge incontinence. This condition occurs in both
men and women and involves an overwhelming urge to urinate immediately, frequently followed
by loss of urine before you can reach a bathroom. Even if you never have an accident, urgency
and urinary frequency can interfere with work and a social life because of the need to keep
running to the bathroom.
Urgency is caused when the bladder muscle, the detrusor, begins to contract and signals a
need to urinate, even when the bladder is not full. Another name for this phenomenon is
detrusor overactivity.

Overactive bladder can result from physical problems that keep your body from halting
involuntary bladder muscle contractions. Such problems include damage to the brain, the spine,
or the nerves extending from the spine to the bladder — for example, from an accident,
diabetes, or neurological disease. Irritating substances within the bladder, such as those
produced during an infection, might also cause the bladder muscle to contract.

Often there is no identifiable cause for overactive bladder, but people are more likely to develop
the problem as they age. Postmenopausal women, in particular, tend to develop this condition,
perhaps because of age-related changes in the bladder lining and muscle. African American
women with incontinence are more likely to report symptoms of overactive bladder than stress
incontinence, while the reverse is true in white women.

A condition called myofascial pelvic pain syndrome has been identified with symptoms that
include overactive bladder accompanied by pain in the pelvic area or a sense of aching,
heaviness, or burning.

In addition, infections of the urinary tract, bladder, or prostate can cause temporary urgency.
Partial blockage of the urinary tract by a bladder stone, a tumor (rarely), or, in men, an enlarged
prostate (a condition known as benign prostatic hyperplasia, or BPH) can cause urgency,
frequency, and sometimes urge incontinence. Surgery for prostate cancer or BPH can trigger
symptoms of overactive bladder, as can freezing (cryotherapy) and radiation seed treatment
(brachytherapy) for prostate cancer.

Neurological diseases (such as Parkinson's disease and multiple sclerosis) can also result in
urge incontinence, as can a stroke. When hospitalized following a stroke, 40% to 60% of
patients have incontinence; by the time they are discharged, 25% still have it, and one year
later, 15% do.
 Performance Oriented Mobility Assessment (POMA)

Description
The Tinetti-test was published by Mary Tinetti (Yale University)
 To assess the gait and balance in older adults and to assess perception of balance and stability
during activities of daily living and fear of falling.
 It is also called Performance-Oriented Mobility Assessment (POMA).
 It also is a very good indicator of the fall risk of an individual.
 It has better test-retest, discriminative and predictive validities concerning fall risk than other
tests including Timed Up and Go test (TUG), one-leg stand and functional reach test.

Intenden Population
It is used in various settings eg those diagnosed with:
 Multiple Sclerosis
 Parkinson's Disease
 Acquired brain injury
 Spinal cord injury
 Stroke
 Elderly population

Procedure
The test requires a hard armless chair, a stopwatch and also, a 15 feet even and uniform walkway.

It has 2 sections:
 one assesses balance abilities in a chair and also in standing
 the other assesses dynamic balance during gait on a 15 feet even walkway

- The patient is to sit in an armless chair and will be asked to rise up and stay standing.
- The patient will then turn 360° and then sit back down
* This is to test the patients' balance.
 Testing this, the evaluator will look at several key points including how does the patient rise
from and sits down on his/her chair, whether or not the patient stays upright while sitting and
standing, what happens when the patients' eyes are closed or when the patient gets a small
push against the sternum.
 Next, the patient will have to walk a few meters at a normal speed, followed by turning and
walking back at a “fast but safe” speed.
 The patient will then sit back down. As well as in the first part of the test, there are some points
the evaluator has to look at. These are the length and height of the steps, the symmetry and
continuity of the steps and straightness of the trunk
NOTE: During this test, the patient can use any assistive devices (walking stick, crutches, zimmer frame)
they would normally use
Interpretation
The Tinetti test has a gait score and a balance score. It uses a 3-point ordinal scale of 0, 1 and 2. Gait is
scored over 12 and balance is scored over 16 totalling 28. The lower the score on the Tinetti test, the
higher the risk of falling.

Tinneti tool score Risk of fall

≤ 18 High
19 -23 Moderate
≤ 24 Low

Gait and Balance

If the patient needs to rise in stages, it is possible that there is a problem with proprioception or
cerebellar problems. A shuffling gait, abnormal knee extension, high stepping, toe dragging and an
inability to stop or turn are all signs of abnormalities during walking. These signs need to be further
evaluated because they could indicate several health problems such as partial vision loss, lowered
strength in the knee or hip joints, problems with proprioception, frontal lobe dysfunction or even
vascular claudication. When the patient falls into his/her chair upon returning it is indicative of poor
knee and/or hip flexion.The study by Usayl I et al. showed that the patients who had a higher score in a
half squat (HS) and decline squat (DC) also had a higher score in Tinetti Performance Oriented Mobility
Assessment (POMA), thus showing a significant correlation between squat and balance assessment in
older patients

Clinimetric Properties
The test and retest values for the POMA-T, POMA-B en POMA-G all varied between .72 and .86. The
interrater reliability values all varied between .80 and .93.6

People with a score lower than 26 will have a higher chance of falling. This test has a sensitivity of 70%
and a specificity of 52%. This means that 70% of the people with a higher fall risk will have a test score
lower than 26. It also means that 52% of the people who have a test score lower than 26 have a higher
fall risk and will have a fall within a year. The people who have a score of 26 or lower have a two-fold
risk of falling.
 Gait Training V.S. Assisted Ambulation

 all individuals needing assistance with ambulation may not be appropriate for
physical therapy.
 If an individual requires the assistance of another for ambulation activities, this
need does not necessarily equate to the need for gait training.
MAIN COMPARISON
 if an individual has no personal goals to increase or improve ambulation abilities,
“assisted ambulation” is appropriate and can be carried out by any caregiver
after appropriate training.

 Assistive devices can be prescribed to broaden a patient’s base of support,

improve balance and stability, or redistribute weight from the lower limbs to help
alleviate joint pain or compensate for weakness or injury. The goals of assistive
device use are to improve independent mobility, reduce disability, delay
functional decline, and decrease the burden of care. Examples of these assistive
devices are canes, crutches and walkers etc.

 Gait training focuses on strengthening weak muscles to return the patient to

functional ambulation. Gait training implies that an analysis of gait and an
evaluation of what specific interventions might enhance gait performance
precede the training.

 When do we use Gait training and Assisted Ambulation?

Answer: It will mostly depend on the functional ambulation ability of the patient. It
will also depend on the personal preference of the patient whether the patient
chooses to improve ambulation ability or utilize assistive devices to accommodate for
his/her needs.
 Pelvic Muscle Exercise and Intervention for Urinary Incontinence

Description:
• Pelvic floor muscles help control release of urine and feces
• Constriction = tighten muscles
• Relax = release of urine and feces

Causes for weak pelvic floor muscles:

• Pregnancy
• Age
• Menopause
• Reproductive organ disorders
• Irritable bowel syndrome

Causes for tight pelvic floor muscles:

• High levels of stress
• Fear
• Anxiety
• High impact exercises
• Heavy lifting

Facts
• Urinary incontinence affects both men and women.
• Drinking a lot of caffeine or alcohol can worsen incontinence, since these beverages increase
the need to urinate.
• Healthy sleep and incontinence are inversely related.
• Pelvic floor dysfunction can start at the menopause
• Pelvic floor exercises are good for your sex life

Exercises to help with urinary incontinence:

• Kegels: Pelvic muscle training, or Kegels, is the practice of contracting and relaxing your
pelvic floor muscles. You may benefit from Kegels if you experience urine leakage from
sneezing, laughing, jumping, or coughing, or have a strong urge to urinate just before losing a
large amount of urine.

• Bird dog: An exercise in balance and stability, bird dog is a full-body move that makes you
engage many muscles at once, including the pelvic floor.

• Pelvic bridge:The bridge is a great exercise for the glutes. If done correctly, it also activates the
pelvic floor muscles in the process. Even without weight, the pause and pulse of this move will
have you feeling it.
3 types of incontinence:

1. STRESS INCONTINENCE
• Occurs when the urethral sphincter, 0elvic floor muscles, or both these structures have been
weakened or damaged
• • Urine may leak ot when you jump, cough, or laugh

2. URGE INCONTINENCE
• Cannot stop the body from having involuntary bladder contractions
• Having the urge to pee even uf the bladder isnt full

3. OVERFLOW INCONTINENCE
• Occurs when something blocks the urine out of the bladder
• The bladder becomes overfilled, distended, and pulling the urethra open until urine will
leak out
The Interdisciplinary Model of Care

- Uses an interdisciplinary medical, psychological, and spiritual approach to the promotion of

comfort and quality of life in patients with a terminal illness and a life expectancy of 6 months or
less
- The IDT model of hospice care prevents many of the communication pitfalls that can impede
quality of care and create patient dissatisfaction.
Specific Services Covered by Medicare Hospice Benefit
- Nursing services*
- Physician services to provide palliation and management of the terminal illness and
related conditions*
- Medical social services provided by a social worker under the direction of a physician*
- Counseling services (chaplain, psychosocial, bereavement)*
- Home health aide services
- Homemaker services
- Medical supplies
- Drugs related to the care of the terminal illness
- Durable medical equipment
- Any other medical supplies
- Physical therapy, occupational therapy, and speech therapy if indicated
- Laboratory testing and other diagnostic studies related to the care of the terminal
illness
The interdisciplinary hospice team:

o physical (physician and nurse),

o functional (consulting therapists, nurses, and nurse’s
aides),
o interpersonal(social workers, psychologists, and
counselors),
o spiritual (chaplain, psychologists, and social workers)
- Volunteers, who complete a comprehensive training course on
the philosophy of hospice, are an important element of each
domain of hospice care.
o They assist with light housework
o For meal preparation.
o They can also provide supportive companionship for
patients and family members.
- Physical therapists are not a required “core service” on the hospice IDT
o Does not require their services to be provided for all patients.
o must be made available to any patient on an “as needed” or “consultative basis

policy by the 2008 Medicare Conditions of Participation for hospice(section 418.92),

Physical therapy, occupational therapy, and speech–language pathology must be
 1. Available, and when provided, offered in a manner consistent with accepted
standards of practice; and
2. Furnished by personnel who meet the qualifications (individuals who are
licensed in the relevant disciplines).
Interdisciplinary Team Meetings.

- each patient in a Medicare-certified hospice receive an interdisciplinary plan of care at the time
of admission, which must be updated by the team at least every 2 weeks
- most hospices hold weekly IDT meetings, which facilitate the coordination of care for both new and existing
patients
- The reports of each core discipline provide a comprehensive picture of the status of each patient
and his or her support system.
- Physical therapists are not considered a core member of the IDT, they may not feel that their
presence at the weekly meetings is appropriate or necessary.
- Patients and their families can have every element of their quality of life addressedatatime when
it is most needed.
-
 FALLS

 Based on the journal article by george fuller, falls are the leading cause
of injury-related visits to emergency departments in the United States
and the primary etiology of accidental deaths in persons over the age of
65 years.
 Falls are a major health problem for older adults. Most falls are caused
by the interaction of multiple risk factors. The more risk factors a person
has, the greater his/her chances of falling.
 Identifying these risk factors can guide an intervention program to
accommodate or ameliorate risks for older adults.

INTRINSIC FALL RISK FACTORS

AGE-RELATED HEALTH CONDITION

CHANGES RELATED
Somatosensory  Decreased light touch  Diabetic/Idiopathic
 Decreased neuropathy
proprioception  Spinal stenosis
 Decreased two-point  Stroke
discrimination  Multiple sclerosis
 Decreased vibration
sense
 Decreased muscle
spindle activity

Visual  Decreased visual acuity  Cataracts

 Decreased contrast  Macular degeneration
sensitivity  Glaucoma
 Decerased depth  Diabetic retinopathy
perception  Stroke
 Use of progressive,
bifocal, or trifocal
corrective lenses
Vestibular  Decreased vestibular  Benign paroxysmal
hair cells positional vertigo
 Decreased vestibular  Unilateral vestibular
nerve fibers hypofunction
 Changes in VOR**  Meniere disease
 Bilateral vestibular
hypofunction
CNS  Decreased coordination  Parkinson’s disease
 Stroke
  Cerebellar atrophy
Neuromuscular  Slowing of muscle  Impaired postural
timing/sequencing alignment
 Decreased  Osteoporosis with
ROM/flexibility vertebral fracture and
 Decreased muscle kyphosis
endurance  Diabetes with distal
 Decreased lower motor neuropathy
extremity muscle  Lower limb joint
strength, torque, and diseases (such as
power arthritis)
 Delayed distal muscle  Spinal stenosis
latency
 Increased cocontraction
 Impaired postural
alignment (such as
kyphosis)
Cardiovascular  Conditions association
with syncope or
lightheadedness
(arrhythmia, orthostatic
hypotension, etc.)

Psychosocial  Fear of falling  Depression

 Cognitive impairment

Other  Incontinence
 Alcohol abuse
Accommodation:

Depth perception = avoid patterned floor surfaces

Black telephone with white lettering on the dial to enhance visual contrast. Large-button phone
numbers also enhance visual acuity

Depth perception is the ability to distinguish distances between objects. Related to loss of color
discrimination is change in depth perception, or the ability to estimate the relative distance and relief of
objects

Lack of color contrast results in a flat visual effect, or decreased depth perception and inability to judge
distances

As a result of the inability to judge distances, older persons may have difficulty estimating the height of
curbs and steps and may have difficulty with activities of daily living that require distance judgment,
including feeding tasks

Related to depth perception is figure–ground, which is the object of focus from a diffuse background. t is
difficult for older individuals to recognize a simple visual figure when it is embedded in a complex figure
background. Specific implications for older persons are in selection of floor coverings.

When a pattern is present on a floor surface, it may create a hazard as older individuals perceive it as
one object or several objects. The avoidance of patterns is therefore recommended for floor surfaces,
particularly in hallways or living areas
Depth perception is also known to decline with age and is additionally affected by increased
susceptibility to glare, loss of visual acuity, dark adaptation, changing needs for illumination and
contrast, and altered color perception

Older drivers need the ability to judge distances between their vehicle and other moving or stationary
objects.

This is critical for judging distances from oncoming cars, maintaining appropriate distances, safely
passing other vehicles, merging onto a highway, or braking before reaching an intersection

Older drivers who experience difficulty with depth perception and are unable to compensate for this
loss should be strongly cautioned to avoid driving

One simple clinical test is to hold your index fingers point upward in front of the patient at eye level, one
finger closer to the patient than the other

Gradually move the index fingers toward each other (one forward, one back), until the patient identifies
when the fingers are parallel or lined up

If the patient’s perception of parallel is off by 3 in. or more, then depth perception may be a problem
and referral to an ophthalmologist for additional investigation is warranted
 CONTRACTURE REDUCTION

A contracture is usually caused by changes in the skin, muscles, tendons, cartilage, or

ligaments that surround the joint and is caused by conditions that limit or prevent movement,
affect muscle tone, or cause weakness.

Any of the following may cause a contracture:

• Joint injury or surgery
• Arthritis or joint infection
• Scarring caused by burns
• Muscular dystrophy or cerebral palsy
• Nerve damage
• Being inactive for a long period of time

Contracture reduction may include:

• Structured range of movement program – including passive and active movements to
increase circulation, provide joint lubrication and to stretch soft tissues.
• Stretching – this may involve the use of splints or casts for prolonged stretch of the soft
tissue surrounding a joint.
• Massage – helps maintain tissue mobility and nutrition.

PRESSURE ULCER MANAGEMENT

Pressure ulcers (PUs) are an important aspect of geriatrics and palliative care that amplifies
morbidity of the chronically bed-ridden patients posing a threat to health-care economy and
resources. PUs can interfere with functional recovery, may be complicated by pain and infection
and can prolong hospital length of stay.

Management includes:
1. Cleanse the wound with saline during each dressing change
2. If necrotic tissue or slough is present consider the use of high pressure irrigation
3. Debride necrotic tissue
4. Do not debride dry black eschar
5. Perform wound care topical dressings
6. Choose dressings that provide a moist wound environment,keep the skin dry surrounding
the ulcer dry,control exudates and eliminate dead space.
7. Reassess the wound with each dressing change to determine whether modification plans
are needed
8. Identify and manage wound infections
9. Clients with stage 3 and 4 ulcers do not respond to conservative therapy

 Behavioral Interventions for Urinary

Incontinence -Instead, they are instructed to walk at a
normal pace to the bathroom and pausing, if
Bladder Training needed, to contract their PFMs
-behavioral intervention most often
recommended as an intervention for
persons with urge UI.
Evidence to support the use of bladder
training for
Main goals of bladder training women with urge UI:
-a randomized controlled trial of women
• Improve bladder capacity aged 55 years or older.
• Restore normal bladder function -Women who received 6 weeks of bladder
training demonstrated a 57% reduction in UI
Burgio described a model: episodes compared to minor improvement
• The sensation of urgency drives observed in the control group.
urinary frequency, leading to -women in the bladder training group
reduced bladder capacity, OAB, and demonstrated sustained improvement at a
UI. 6-month outcome assessment.
• In this model, the introduction of
bladder training (expanding the Note: Benefit of using bladder training in
voiding interval) allows the patient to conjunction with PFM exercise is less
break the cycle. certain.

Bladder training: A comparative study of three interventions

-requires the patient to gradually (bladder training alone, PFM exercise
increase the time interval (usually by 15- alone, PFM exercise combined with
minute intervals) between voids until an bladder training) showed an immediate
acceptable voiding schedule is reached. postintervention advantage to combined
-Voiding schedule of every 3 to 4 hours is therapy on the number of incontinent
Optimal (but depends on the patient’s episodes, HRQOL, and treatment
preintervention voiding schedule) satisfaction in a
sample of women with stress UI, urge UI,
and mixed UI. (But differences in outcomes
To delay voiding: between the three interventions did not
-patient must be able to suppress the persist after 3 months.)
sensation of urgency.
-efficacy of bladder training as a single
Suggested urge suppression intervention for men with RP is unclear.
strategies: -One trial that examined a multicomponent
• Distraction to another (preferably behavioral intervention (PFM exercise,
mental) task voiding schedules, and behavioral methods
• Taking deep breaths to relax, to manage
• Contracting the PFMs several times urgency and postpone voiding) to reduce
to inhibit bladder contractions. urge UI
Note: Patients are also taught to avoid postprostatectomy showed an 80.7%
rushing reduction in symptoms.
to the bathroom, which may increase
abdominal Lifestyle Measures
pressure and trigger bladder contractions.
-Scientific evidence upon which to base -one study found reducing fluid intake
specific improved UI episodes in women with either
recommendations is quite limited. For stress UI or idiopathic detrusor overactivity,
example, despite its potential to impact but reduced frequency and urgency in only
general health status, the effect of smoking those with detrusor overactivity
cessation on lower urinary tract symptoms -results of this study should be applied
is not known. cautiously given the risks associated with
restricting fluids, including dehydration,
-However, there is growing evidence to constipation, and urinary tract infection.
support recommendations for -There are very few data to support
recommendations for adjusting fluid intake
• weight loss -Some patients with UI will report excessive
• caffeine reduction water
• fluid management intake and fail to recognize the association
Also, clinicians commonly advise patients between fluid intake and bladder symptoms.
with OAB or urge UI to restrict foods
believed to irritate the bladder Note: recommendation
(particularly, artificial sweeteners, citrus to reduce fluid intake may help improve
fruits, vegetables, and/or juices)- here is no bladder symptoms, particularly urinary
scientific urgency and frequency
support to justify these recommendations to
persons with OAB or urge UI. Caffeine Reduction
-Evidence to support caffeine reduction
Weight Loss recommendations can be gleaned from
-emerging evidence to support weight loss clinical trials that tested concomitant
recommendations as an intervention for interventions to reduce female urge UI.
female UI -one study, women who consumed more
-one study, morbidly obese women with than 100 mg/day of caffeine either
stress UI and urge UI experienced underwent bladder training or bladder
significant improvements in UI following a training combined with recommendations
weight loss of 45 to 50 kg after bariatric and strategies to reduce caffeine.
surgery
-Remarkably, another study showed that a -Those in the combined intervention
weight loss of only 16 kg by women with achieved a 58% (from a mean 238.7
stress UI, urge UI, or mixed UI enrolled in a mg/day to a mean 96.5 mg/day) caffeine
conventional weight loss program resulted reduction and reported statistically greater
in a 60% reduction in weekly UI episodes improvements in voiding frequency and
urgency episodes compared to women who
Note: Observed improvements were received bladder training alone
sustained 6 months following the weight
reduction intervention -The 96.5 mg/day equates to less than the
caffeine content of a 5-ounce cup of brewed
-In addition, a 50% reduction in weekly UI coffee (reportedly contains 128 mg
episodes was found in women who lost as caffeine).
little as 5% to 10% of their baseline weight -An 8-oz glass of iced tea and an 8-oz glass
of cola soft drink are reported to contain 47
mg and 25 mg of caffeine, respectively.
Fluid Management
-Many persons with UI restrict fluid intake in -Another study: 64% of women who
an effort to manage their UI reduced caffeine intake were found to have
decreased UI episodes
-Some patients are very reluctant to reduce
their caffeine intake. Suggesting a trial
period of caffeine reduction may be more
acceptable.
-In addition, caffeine reduction should be
done gradually to prevent the patient from
experiencing severe headaches.

SUMMARY
Behavioral Intervention on Urge
Incontinence Bladder training
-suppression of urgency
-Weight loss

Fluid management -reduction of fluid

intake Caffeine Reduction - coffee and
soda
Lifestyle measures
-artificial sweeteners
-citrus fruits -vegetables
-juices
PHYSICAL THERAPY PATIENT MANAGEMENT IN THE LTC SETTING
What is LTC?
● LTC stands for long-term care.
● According to Guccione (2012), LTC residents are for whatever reasons, reside in the
nursing home for periods of time, often for the remainder of their lives
● LTC residents show the most variability in functional abilities, ranging from being
independent ambulator to being totally bed-bound
● The primary goal is to return the resident to a prior level of function or higher
○ Prior level of function is not as high as those patients who are in skilled-nursing
facility but it does not mean that they cannot have the ability to display significant
improvement

What is frailty?
● The term ​frail​ is a cluster of medical conditions and frailty is not a disease but a
combination of a variety of medical problems
● In a study conducted, frailty was a considered a reliable predictor a general decline in
health
● The severityFrailty can be measured by using the ​“Modified Physical Performance
Test” ​by Brown et. al

What are the roles of Physical therapy in the LTC setting?

● Primary role of PT: function as a team member who will delegate tasks and follow
through with other team members
● PTs performing the screening should visually inspect and/or observe the resident
○ Changes in ability to transfer & ambulate
○ Any new onset of pain
○ Worsening or development of contractures
○ New difficulty in eating, swallowing or speaking
○ Difficulty propeling the wheelchair
○ Inspection of the prosthesis, braces or splints
○ Ability to maintain basic self-care activities - indicates if there has been decline,
improvement or stabilization of a condition
 Balance Measure:

Berg Balance Scale

What is the Berg Balance Test?

● The Berg Balance Scale (BBS) was developed by ​Katherine Berg​ in 1989 to ​measure balance
ability (static and dynamic) among older adults
● a qualitative measure that assesses balance via performing functional activities such as reaching,
bending, transferring, and standing that incorporates most components of postural control
● The BBS is particularly helpful in determining sitting and standing balance.

Type of Balance​ ​Assessed (Sitting, Standing, Dynamic Standing, Gait:​ ​Examines standing and
dynamic standing

Intended population:​Elderly population with impairment of balance, patients with acute stroke
(Berg et al 1995, Usuda et al 1998).

Items included:

14 total items:

1. sitting to standing
2. standing unsupported
3. sitting with back unsupported but feet supported on floor or on a stool
4. standing to sitting
5. transfers
6. standing unsupported with eyes closed
7. standing unsupported with feet together
8. reaching forward with outstretched arm while standing
9. pick up object from the floor from a standing position
10. turning to look behind over left and right shoulders while standing
11. turn 360 degrees
12. place alternate foot on step or stool while standing unsupported
13. standing unsupported one foot in front
14. standing on one leg

Equipment Required: Chair, stool, yardstick, stopwatch

Scoring:
● Each item is scored along a 5-point scale, ranging from 0 to 4, each grade with well-established
criteria.
● Zero indicates the lowest level of function and 4 the highest level of function.
● The total score ranges from 0 to 56.
● The BBS is reliable (both inter- and intratester) and has concurrent and construct validity.
Interpretation of Scores:

Traditional:

● Score <45: high risk for falls

● Scores ≤36: 100% chance of falling in the next 6 months in older adults
● However, it has been suggested that the BBS is best used as a score with no cutoff value
ascribed to fall risk, as fall risk increases significantly as the score on the test decreases

Muir and Berg:

● suggests an alternative scoring system as well as suggesting that the BBS is more effective in
identifying those who will fall more than once than those who have fallen one time only
● a cutoff score of 40 to predict those who will experience multiple falls (positive likelihood ratio of
5.19 with 95% confidence interval [CI] of 2.29 to 11.75) and injurious falls (positive likelihood ratio
of 3.3 with 95% CI of 1.40 to 7.76).

Shumway-Cook et al model:

● a score of 36 or less indicated a nearly 100% chance of falling in the next 6 months in older
adults
● Even subjects who achieve a very high score (53 or 54 of 56) only have a moderate assurance
that they are not at risk for a fall in the next few months.

Administration:​ A skilled evaluator can complete the test in less than 15-20 minutes

Limitations:

● In ataxic clients it cannot reflect problems in the performance of daily living activities
○ caused by the effects of ataxia on the upper extremities
● No measures of gait are directly recorded within the scale
● The BBS is less useful in confirming someone is at low risk of falling.

The Main Uses of the Measure in Older Adult Population

● Used for patients who exhibit a decline in function, self-report a loss of balance, or have
unexplained falls
● Can predict fall risk of older adults. Good to use for persons of lower functional ability also
because the tests incorporate sitting and standing but no locomotion. A person cannot use an
assistive device
References:

Berg Balance Scale. (2019, September 13). Physiopedia, . Retrieved 08:26, November 22,
2020 from https://www.physio-pedia.com/index.php?title=Berg_Balance_Scale&oldid=222724.

Guccione, A. A. (2000). Geriatric physical therapy. St. Louis: Mosby.

 TOPIC: RESPONSE STRATEGIES TO POSTURAL PERTURBATIONS
A postural perturbation is a sudden change in conditions that displaces the body posture away from equilibrium. As physical therapists, it is
important for us for learn these response strategies especially in dealing with geriatric patients, whose balance is often times disturbed. If we do these
movement patterns appropriately, no loss of balance will occur. It is our job as PTs to prevent our patients from falls and accidents.

STRATEGY DESCRIPTION PURPOSE CHARACTERISTICS APPLICATION FACTS

• Amplitude of • Great first line defense 1) Distal to proximal • It is applied when you step • It is the most frequently
ANKLE unexpected against falls since it self activation of muscles
on uneven ground, you will utilized balance recovery
perturbation: Slow and is designed to move in all 2) Muscles activated on side notice sometimes your foot strategy.
low amplitude
directions
contralateral to direction will autocorrect before you
• Contact surface firm, • Designed to use its that COG is shifted or can even consciously
wide, and longer than surrounding musculature perturbed ("elongation of realize you are starting to
foot
to keep you standing the weight-bearing side" get out of your center of
• Head movements in upright balance.

phase with hips

• During small shifts or
• BOS: Feet shoulder- perturbations of COG

width apart
• When the task requires
• Mechanism: Detected maintenance of upright
through ankle posture
proprioceptors

• Response: Small
amplitude sway at the
ankle where hips and
head move in the same
direction

HIP • Amplitude of • If our ankle strategy fails 1) Proximal to distal • It is a swaying of the hips • As we age, due to a loss of
unexpected to keep our center of activation of muscles
that counteract larger flexibility or strength, our hip
perturbation: Fast or gravity over our base of 2) Muscles activated on the perturbations, basically strategy becomes more
large amplitude
support, then we move side toward which COG is moving our center of prominent.
• Surface if unstable or our hips to compensate.
shifted or perturbed gravity around to keep it
shorter than feet
• Used if a perturbation is over our base of support.

• Head movement out of too large to be • During perturbations that

phase with hips
successfully handled by are large in comparison
• BOS: Narrow
the ankle strategy with the supporting surface

• Mechanism: Detected • When the task requires a

through vestibular large or rapid shift in COG
system

• Response: Large
amplitude sway where
head and hips move in
opposite direction

Gilo. Palomar. Trivilegio. Villaran

 • Amplitude of • When the perturbation is 1) Limits of stability is • It is when your center of • It’s effective, but not efficient.
STEPPING unexpected so large that our ankle or reached or exceeded
gravity is pushed so far,
perturbation: Fast or hip strategies cannot 2) Muscles activate to allow a your last resort is to make
large amplitude or when compensate for it, we compensatory weight shift your base of support larger
other strategies fail
take a step.
and take a step.

• BOS moves to “catch up • Used to prevent a fall • During large, gross

with BOS”
perturbations
• BOS: Shoulder-width
part

• Mechanism: Detected
through vestibular
system

• Response: Change in
BOS such that there is a
step

REFERENCES:
• https://www.slideshare.net/mobile/mallishan/balance-83030931

• https://www.professionalptandtraining.com/balance-strategy-basics/

• https://media.lanecc.edu/users/howardc/PTA204L/204LBalanceInterventions/204LBalanceInterventions_print.html

• https://www.fcnntc.org/wp-content/uploads/2016/12/Reactive-Balance-Handout-Accessible.pdf

Gilo. Palomar. Trivilegio. Villaran

Gilo. Palomar. Trivilegio. Villaran
 AEROBIC & FLEXBILITY EXERCISES

According to the US Office of Disease Prevention & Health Promotion, there are strong
evidences that physical activity & exercise for the older adults can result to the ff

• Lower risk of early death

• Lower risk of coronary heart disease
• Lower risk of stroke
• Lower risk of high blood pressure
• Lower risk of adverse blood lipid profile
• Lower risk of type II diabetes mellitus
• Lower risk of metabolic syndrome
• Lower risk of colon cancer
• Lower risk of breast cancer
• Prevention of weight gain
• Weight loss, particularly when combined with reduced calorie
• intake
• Improved cardiorespiratory and muscular fitness
• Prevention of falls
• Reduced depression
• Better cognitive function (for older adults)

Other Benefits Include

• Enhanced immune function through aerobic training. Aerobic, not resistance, training
has been shown to impact chronic inflammation and thereby impact the immune
system.
• Increased joint ROM. This is believed to be due to the actual performance of movement
rather than the strengthening exercises.

AEROBIC EXERCISES FOR OLDER ADULTS

Factors to consider when prescribing aerobic exercises to older adults

1. Age-related decrease in maximum HR

2. Age-related decrease in Stroke volume, resulting to decreased CO
3. Decreased Arteriovenous O2 difference due to decreased lean body mass & low O2
carrying capacity
4. Decreased Maximum O2 reuptake
5. Increased BP due to increase in Peripheral vascular resistance
6. Age-related RR increase & decrease in maximum voluntary ventilation

TENEFRANCIA º RICHARDSON º DELA LLANA

Aerobic exercise modes can be categorized into weight-bearing (high- and low- impact) and
non–weight-bearing activities

• The Physical Activity Guidelines for Americans recommend that older adults participate
in 150 minutes a week of moderate intensity such as brisk walking or 75 minutes a week
of vigorous-intensity aerobic exercise like jogging or running. Furthermore, aerobic
exercise should preferably be performed in episodes of at least 10 minutes and spread
throughout the week.

• The talk test is a technique for aerobic exercise which measures intensity. The concept
of being able to maintain a conversation or talk while performing an activity is thought
to correlate with moderate-intensity aerobic exercise, while only being able to say a few
words without taking a breath or having difficulty maintaining a conversation correlates
with vigorous intensity

FLEXIBILITY EXERCISES FOR THE OLDER ADULTS

Important points to remember when prescribing flexibility exercises for older adults

1. A low-intensity, long-duration stretch is the safest & most effective form of stretch
2. There is an age-related decrease in maximum tensile strength & slow rate of adaptation
to tissue stress resulting in increased tendency for tears with stretching
3. With co-morbidities such as nutritional deficiencies, hormonal imbalances, and dialysis,
connective tissue may be- come injured at lower levels of tissue stress.

Examples are

• Studies show that straight leg raise stretches held 15, 30, or 60 seconds were effective
for increasing the combined motion of hip flexion and knee extension for older adults

TENEFRANCIA º RICHARDSON º DELA LLANA

 • Yoga is a traditional Indian form of exercise combining resistance, balance, and flexibility
exercises. Initial studies have shown yoga to be an appropriate and simple-to-learn
activity for older adults that can improve joint mobility.

For long-lasting effects of flexibility and stretching, it is critical to use any newly gained range of
motion (ROM). Encourage the older adult to include daily activities that require reaching
overhead, out to the side, and behind the back, as well as moving their trunk, neck, and lower
extremity joints through as much ROM as possible.

References
Kisner, C., Colby, L.A, Borstad, J. (2018). Therapeutic Exercise. Philadelphia, PA: F.A Davis
Guccione, A.A, Wong, R.A, Avers, D. (2012). Geriatric Physical Therapy. Elsevier

TENEFRANCIA º RICHARDSON º DELA LLANA

Timed Up and Go Test (TUG)

Objective

To determine fall risk and measure the progress of balance, sit to stand and walking.

Simple screening test that is a sensitive and specific measure of probability for falls among older
adults[1].
Intended Population
This test was initially designed for elderly persons, but is used for in other populations eg
Parkinson's - This tool is validated for a population with Parkinson’s Disease; Multiple Sclerosis;
Hip fracture; Alzheimers; CVA; TKR or THR; Huntington Disease
It is one of the 4 tests used in the The Balance Outcome Measure for Elder Rehabilitation
(BOOMER)
Materials Needed
One chair with armrest
Stopwatch
Tape (to mark 3 meters)
Method
Patients wear their regular footwear and can use a walking aid, if needed.
The patient starts in a seated position
The patient stands up upon therapist’s command: walks 3 meters, turns around, walks back to
the chair and sits down.
The time stops when the patient is seated.
Be sure to document the assistive device used.
Note: A practice trial should be completed before the timed trial

Observations
Observe the patient’s postural stability, gait, stride length, and sway.

Note all that apply: Slow tentative pace; Loss of balance; Short strides; Little or no arm swing;
Steadying self on walls; Shuffling; En bloc turning; Not using assistive device properly.
These changes may signify neurological problems that require further evaluation[2].
Cut-off time for high risk of falls
An older adult who takes ≥12 seconds to complete the TUG is at risk for falling.[2]

Cut of scores indicating risk of falls by Population (in seconds)

Community dwelling adults - 13.5

Older stroke patients - 14
Frail elderly - 32.6
LE amputees - 19
PD - 11.5
Hip OA - 10 -
Vestibular disorders - 11.1[3]
Cut-off times to classify subjects as high risk for falling vary based on the study and participants.