Addressing Visual Deficits and Vestibular Screening for Balance Assessment

Dr. Dustin Jones // #GeriOnICE // www.ptonice.com 

In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult division leader Dustin Jones discusses a framework to begin to better assess balance & tailor focused interventions for patients, including assessing risk factors, understanding inputs that affect balance, and how to measure outputs from balance.

Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog.

If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

EPISODE TRANSCRIPTION

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DUSTIN JONES Good morning, folks. You are listening to the PT on Ice daily show brought to you by the Institute of Clinical Excellence. My name is Dustin Jones, one of the lead faculty within the older adult division, and we are going to be talking about a framework for balance, about how we can think about balance from the assessment side of things. over to the intervention side as well. I feel like this area is very kind of misunderstood in the rehabilitation realm and it's often handled very poorly from what I've seen and I'm definitely guilty of this as well. Let's kind of play out the typical scenario when we're talking about trying to assess and improve people's balance, right? We have someone if you're an outpatient they likely came to you for you know some type of painful issue right back pain shoulder pain whatever and then you realize oh this person you know reports that they feel unsteady or that you may notice it yourself or you may have gotten a referral that said they've had a fall and we need to look at balance then we do our assessment and typically what we're doing is throwing some type of of you know quote-unquote balance outcome measure that we learned in school, probably something like the Berg, you know, balance test, where we take them through that test and we see a score and we say, oh my gosh, all right, you are at risk of a fall. I saw some deficits in some of these activities and man, all right, I'm gonna give you my balance program, right? So you've got your balance exercises. There's probably, you know, some tandem stance in there, semi-tandem, maybe one-legged stance if you're feeling funky, right? you're maybe doing some obstacle courses, maybe tossing a ball back and forth, you may be having to stand on an Airex foam pad, right? We kind of got this kind of generic balance program that does challenge people's balance capacities, but what we often see is that that generalized program is not specific to the deficits that that person provides. Balance, I would say out of any other facet of performance is probably one of the most complicated, because there's so many different variables that can influence someone's balance ability, and we need to identify those and then address those specifically, as opposed to giving these kind of generalized balance exercises, quote-unquote balance program, crossing our fingers and hoping that they actually make a significant difference in these people's lives. All right, so let's talk about a framework for assessment that's ultimately gonna lead to intervention. I think one of the big takeaways for many of us when we start to really look at people's balance abilities is we have to zoom out and look beyond their performance on outcome measures. We focus solely on that, and we miss the boat on some very, very important factors and variables that are contributing to that poor performance in the outcome measure that we see. All right, so think of this in three steps from the assessment side. You want to look at risk factors, you want to look at inputs, and then you want to look at outputs. If you go through those steps, you're going to get some very, very valuable information. I'm going to go through each of those three. RISK FACTORS FOR FALLING All right, so risk factors. We can put risk factors that are going to influence people's balance ability or increase their risk of falling in kind of two buckets is how we typically think about this. Intrinsic and then extrinsic risk factors. These are areas that some of y'all may be thinking about, talking to them, asking questions, maybe getting a good idea, but a lot of folks may be completely ignoring some of these things, right? So like intrinsic risk factors could be their medical history, right? Permanent medical diagnoses that are gonna have an influence on balance. Type 2 diabetes, if they have peripheral neuropathy, they don't have that somatosensory input, they're going to have issues. Think Parkinson's disease. If they have Parkinson's disease, they probably have some issues with initiation of movement, maybe reactive, postural control is a little impaired, that's going to influence their balance. We need to have a good idea of their medical history. We need to have a good idea of their current medications. Think of the last time you did medication reconciliation. There are a lot of medications that can actually impair balance, balance capacity, reactive, speed, that can ultimately increase the risk of falling. These medications are in their own category called falls risk increasing drugs. Other things that we can think about is there their vision, their foot health, their footwear, for example. There's a whole host of these different intrinsic variables that are a lot, right? There's a lot of things to work through. but they will give you valuable information that is contributing to their impaired performance on some of the outcome measures that you're seeing. There's a lot, a lot of intrinsic risk factors. What I'm going to point you to that's going to be a really helpful resource is the CDC's study, S-T-E-A-D-I. This is going to give you a framework to be able to work through some of these contributing variables, particularly the intrinsic risk factors, that can negatively impact balance. And it'll give you a really good framework to be able to address those. Then we have our extrinsic risk factors. This could be assistive device use, the fitting of the assistive device, which we often see it's not properly fitted, whether it's a cane walker, so on and so forth. What's the home look like? Do they have that pesky rug that they end up tripping over? almost every day, right? Can we do something about that? Probably not, but you can go ahead and try. We can think about lighting in certain areas, particularly at night. Let's say if they have nocturia and they have to go use the bathroom at night, we need a well-lit area to reduce their risk of having a fall, improve their balance capacity in that particular situation. So CDC study is going to be very, very helpful for you to work through some of these risk factors, intrinsic and extrinsic, all right? So I would start there. So that's risk factors. Get a good idea of that. Check. INPUTS THAT AFFECT BALANCE Next is going to be inputs. This is where we're looking at those afferent signals, those three main systems that are giving us really helpful information that allow us to execute and maintain our balance. That's that somatosensory system, the visual system, and then the vestibular system. There's some different ways we can check this. From the somatosensory side, we could look at their proprioception, their joint position sense. We can do this starting distally, maybe at the big toe, and get a good idea if they're able to tell where their big toe is in space. that's going to be really helpful because that's going to carry over to their proprioception when they're on their feet navigating a complex environment, for example. Do they have protective sensation? This could be monofilament testing where we're seeing if they're able to be able to feel that little pinprick that seems Weinstein monofilament. If you're working with someone that has blood sugar issues, type 2 diabetes is on their chart, This is something you definitely want to check because that's going to influence that input, that information that they're getting that's going to negatively influence their output that we're seeing with that outcome measure and there's some things that we can do about that. Then we look at their visual system. How's their visual acuity? How's their depth perception? How are their visual fields? We need to have a good idea of the health of their visual system because we may want to make a referral to get it reassessed if it's been over 10, 15 years since they've updated that prescription in terms of their eyeglasses, or we may need to teach compensatory strategies to overcome some of their depth perception issues or their visual field loss that they have. You could throw all kinds of generic balance exercise at these people, but if they have visual deficits, you need to have visual specific interventions that are addressing that visual deficit. And oftentimes it may be compensation, right? So we need to address those inputs. And then the vestibular system. This is where we can do a vestibular screening. We can look at their smooth pursuits, for example, which is more kind of in the visual realm, but it's very closely tied to that vestibular system. Smooth pursuits, vestibulocular reflex, or that VOR. How is the health of that VOR? Is it intact? Are they able to cancel that VOR and be able to move their head and eyes at the same time without an onset of symptoms? And then we can do different positional testing as well. If we can do a vestibular screen, that is gonna be very helpful to identify, hey, this is more of a vestibular issue than anything. You doing your tandem stance, tossing a balloon back and forth, probably ain't gonna do much for that, right? So it's gonna influence our interventions. OUTPUTS FROM BALANCE So we take those risk factors, we take the information from the inputs, and then we do the outputs, which is our outcome measures that we typically think about. Many folks will do a Berg balance test, That. is not the perfect test for everyone, right? There's a lot of issues with the Berg Balance Score. It doesn't really address a lot of different variables of balance in terms of balance performance. What we really like to recommend for folks is looking at something like the Mini Best Test. It is more of a well-rounded test. It looks at people's ability to anticipate maybe a destabilizing event, maybe their ability to react to a perturbation in terms of their reactive postural control. How do they handle different scenarios where we've limited vision or limited that somatosensory input or kind of muddy the water in terms of the vestibular input? How do those people respond in that situation? How they do in a dynamic gait scenario where they have to do different tasks or they have to do, they have to emulate but then also add on a cognitive dual task. That mini best test is going to reveal a whole host of different common scenarios that these folks are going to be struggling with that we can work into our intervention plan. For someone that may be more in a seated position most of the time, we can do the FIS, the function and sitting test, which is as well-rounded as the mini best test that will give you a good idea of their performance in a seated position. And so we take those risk factors, we take those inputs, and we take those outputs in our assessment. And then what we find, we have a individualized, tailored program to that person. And so for some people, the first thing you may do is call their physician or pharmacist to have their medications looked because they're on a couple of FRIDS or false risk increasing drugs that we need to take a look and make sure that they're still appropriate and they're still necessary because we know that they have a negative influence on people's balance ability. You may realize that, man, this person is very visually dependent, that as soon as we close our eyes and we're asking more of the vestibular system and the somatosensory system, their balance really starts to crumble. Then we know, all right, we need to maybe restrict their vision in some of these balance training activities to really strengthen up these other systems, to be able to compensate in the event that we don't have that visual input, make these people more resilient. And you may notice, maybe in the mini best tests, where man, when we do that cognitive dual task, timed up and go, that's a part of the dynamic gate portion of the mini best test, Betty's performance really, really crashes. but she did fine on everything else. Well, what do we need to do? We need to do some balance-based activities where we are going to add on a cognitive dual task. There's so many things out in the real world that demand that, we can practice that in our sessions. And so you go through those risk factors, you go through those inputs, you go through those outputs, and you're gonna get a very tailored program that's going to address that person's specific deficits to overcome them and make a significant improvement in their balance ability. Right? How we typically do it where we're just giving our general balance program to people not really knowing what the true deficits are. It's like throwing darts blindfolded. You're just crossing your fingers, praying to God that you're going to hit that bullseye. Take the blindfold off, assess that person, understand their deficits through that framework, and then you'll be throwing those darts, hitting bullseyes every single time. All right. I will drop some links in to the comments. You can shoot me a direct message as well, and I can give you those links. The big ones are going to be the CDC study. It's going to give you that framework to particularly look at the risk factors. That's what that one's really helpful for. and then I'll link to that mini best test and then the FIST, the function and sitting test as well. So you all have some resources as a result of today's episode. All right, hit me up with any questions. Let me know your thoughts, any other things that you'd add to the conversation around balance. I think we can really level up here. SUMMARY If you want to learn more about balance, if you want to practice some of these interventions of how we can take that information and really put it into a tailored program, I want to recommend our live course, MMOA Live, where we give a bunch of intervention ideas related to this framework. We've got a bunch of courses coming up. I'll just mention the ones coming up in June. We're going to be in Scottsdale, Arizona, June 1st and 2nd, in Spring, Texas, June 8th and 9th, and then we'll be in Charlotte, North Carolina, June 22nd, 23rd. We also hit on this in depth in our MMOA level 2 course where we take a step deeper into the topic of balance. Alright, well I'm gonna get off here. We got our first MMOA level 1 call for this cohort coming up in about 15 minutes. I hope you all have a lovely rest of your Wednesday and I'll talk to you soon.

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