Balance program holds key to fewer falls, healthier patients
Rehab center demonstrates positive outcomes
Fall risk among the elderly is a growing problem, and providers traditionally don’t address it until patients already have suffered injuries from falling. However, a Maine rehab facility has formed a program designed to reduce fall risk among patients who have health problems that place them at high risk for injury, such as patients who have Parkinson’s disease.
The program, called Balance and Safety Enhancement (BASE), is designed to evaluate patients for balance and fall risk and then create a training program for those who have balance problems, says Kim Collett, MSc, PT, a physical therapist with MaineGeneral Medical Center in Waterville.
Before starting the program, the hospital sometimes received referrals of patients who had frequent falls, yet the facility already had a $25,000 computerized balance testing machine. So it was a logical step to develop a special fall prevention program, Collett adds. "We saw the need, we had the equipment, and we had the knowledge base, so we developed the program," Collett says.
The multidisciplinary program typically provides six weeks of balance training with two one-hour sessions per week. Patients are evaluated by both a physical therapist and an occupational therapist. So far, the program has proven a success. Objective tests that compare baseline and discharge assessments of patients’ balance show remarkable improvements, at least on an individual patient level. (Composite outcome scores are not yet available.) Also, balance program participants rate their satisfaction in the good or excellent range.
Here are the steps the program takes:
1. Assess patients’ balance at initial evaluation.
The program evaluates patients in two sessions, each lasting an hour to 1.5 hours. The first day involves testing of balance and strength coordination, as well as obtaining a medical history. Both physical and occupational therapists conduct the evaluation, Collett says.
The PT goes over the patient’s fall history and checks blood pressure, range of motion, strength, reflexes, coordination, balance, and ability to walk. The OT conducts a mini-mental exam and evaluates the patient’s vestibular system, although the PT might also do this. The OT also uses the functional assessment tool to review the patient’s limitations with mobility skills, household tasks, activities of daily living, and work duties.
Machine provides objective measure
On the second day of evaluation, therapists assess the patient’s balance and walking ability on the computerized balance-testing machine. "The machine is a beautiful objective measure, a wonderful adjunct to our evaluation and treatment program," Collett says. "With this program, everybody has the opportunity to have their balance evaluated at the beginning and at the end of the program."
Patients are shown a red-colored block drawing that indicates when they score below normal for their age group. Green blocks indicate that the patient has scored within the normal range. "First, the patient will stand still with eyes open, and then the patient will stand still with eyes closed," Collett explains. "Third, the patient stands on a piece of foam with eyes open and then again with eyes closed."
The machine measures patients’ sway during these four tasks, and this is what is tested again in six weeks after the program has been completed. The machine provides a good visual feedback tool that helps patients learn where their balance should be, Collett adds.
2. Provide individualized balance program.
Although the program is designed to address each patient’s particular strengths and weaknesses, there is a general outline of what will be covered during each session. Here’s the outline:
- Week 1, session 1: Description of program and introduction to balance.
- Week 1, session 2: Fall facts and statistics; hearing and vision.
- Week 2, session 1: Home safety.
- Week 2, session 2: Community safety.
- Week 3, session 1: Re-assessment and review.
- Week 3, session 2: Re-assessments.
- Week 4, session 1: Proper footwear and foot care.
- Week 4, session 2: Adaptive equipment.
- Week 5, session 1: Medications and their effect on balance.
- Week 5, session 2: Eye-head exercises.
- Week 6, session 1: Stairs, transfers, and outdoor safety.
- Week 6, session 2: Course evaluation, review, and questions.
Combining lectures with exercises
Patients enrolled in the six-week program receive progressively challenging balance and walking activities led by physical and occupational therapists and PT and OT assistants. Sessions combine a lecture format with exercises in the gymnasium, corridors, and outdoors. The program’s goals include the following:
- improve people’s balance and walking ability;
- teach fall prevention strategies to patients;
- increase their general fitness level;
- decrease their dizziness or vertigo;
- teach patients about their condition and how they can become independent in symptom management.
3. Educate patients about fall prevention.
PTs and OTs teach patients how to prevent falls in their homes, and they review fall safety within the community. "We teach people how to get off the floor if they do have a fall, and we review medications and their effects on balance," Collett says. "We also talk about proper footwear and foot care as reviewed by an orthotist."
The OT or an audiologist will talk with patients about hearing and vision problems that can affect balance. "The staff who develop and carry out the program have specialty training in balance education, vestibular rehabilitation, and neurological and geriatric medicine," Collett says.
4. Establish referral base and reimbursement sources.
Program participants are referred by physicians and may include anyone who has a neurological condition, such as multiple sclerosis, cerebrovascular accident, and Parkinson’s disease. Others who can be referred to the program include patients who’ve had surgery on their neck or spinal cord, people with vertigo or vestibular problems, and the generally frail elderly who have a history of falling, Collett says. Osteoporosis patients are referred to the rehab facility’s special osteoporosis program, although once they complete that program, they may be referred to the balance program for further fall safety education and training, she says.
Medicare and most private insurers have readily paid for the balance program, and a program case manager will assist patients in investigating their insurance coverage when necessary, Collett adds. The only drawback is that none of the payers can be billed for the educational components of the program.
So far, the program has had little difficulty in obtaining referrals. The only marketing has been distribution of a pamphlet to doctor’s offices and participation in a senior health day. From September 1999 through June 2001, the program held nine classes for an average of four classes per year. There typically are six to eight participants per class, Collett says. "It’s a great service," she adds. "And we offer a six-month retest free of charge to all participants."
5. Track outcomes.
The overall outcomes have not yet been determined, but individual outcomes look very promising, Collett says. Here’s what the program has found on the four major outcome measures:
• Berg Balance Scale: This test was scored as a zero if a patient showed a decrease in the scale score, one point if the patient had no change or a change that was less than 1.0, and two points if there is an increase of 1.0 or greater. Based on this type of scoring, there were a total of 56 points to be obtained. One patient’s score before the program was 31, and at the end of the program the same patient scored 56. In another case, a patient’s score increased from 47 to 56, and yet another patient’s score increased from 34 to 52.
• Timed "up and go" test: This test times how long it takes a patient to stand, walk three meters, turn around, and walk back to sit down. A patient who scores under 15 seconds typically is more independent in activities of daily living. One patient in the balance program scored 22 seconds at the initial evaluation and nine seconds at discharge; a second patient scored 19 seconds initially and 11 seconds at discharge; a third patient improved the score from 12 seconds to eight seconds; and a fourth patient had an improvement from 13 seconds to eight seconds.
• Functional reach test: This test measures in inches the patient’s ability to lean or reach forward without losing balance. Any score over 10 inches is considered evidence that the patient is more independent. Patients enrolled in the balance program showed improvements in this area, as well. For instance, one patient scored four inches at initial evaluation and 12.5 inches at discharge, and another patient scored six inches at initial evaluation and 11 inches at discharge.
• Patient satisfaction survey: The rehab facility’s goal was to have a 75% satisfaction outcome among 95% or greater of patients. The survey was scored from one to four, with one being poor and four being excellent. Scores of three and four were considered acceptable. Although the total has not yet been calculated, the most recent balance class gave the program scores of all threes and fours (good and excellent) on the satisfaction survey.
Need more information?
• Kim Collett, MSc, PT, Physical Therapist, Physical Therapy Dept., MaineGeneral Medical Center, 30 Chase Ave., Waterville, ME 04901. Telephone: (207) 872-4400.
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