Cedar Court Healthsouth Rehabilitation Hospital

“SAFE WALKERS” Outpatient falls prevention and

balance programEryn Wait (Occupational Therapist)

Tiana Wong (Physiotherapist)

Cedar Court: overview

• CCHS started out as a small hospital in the 1930’s, therapy services introduced in 1980

• Purchased by Healthsouth, USA in 1997

• Present day, 80 bed inpatient capacity with orthopaedic/musculoskeltal unit, neurology unit, cardiac-respiratory unit, ABI unit and sleep study unit

Outpatient programs

• Large outpatient program scope:

• Neurological

(stroke, parkinson’s/movement disorders, MS, neuropathies & myopathies)

• Vestibular

(dizziness/vertigo, balance and mobility problems leading to falls)

Outpatient programs

• Acquired Brain Injury

(Traumatic head injury)

• Orthopaedic rehabilitation

(post-joint replacement or reconstruction surgery, fractures, spinal surgery or multi-trauma)

Outpatient programs

• Musculo-skeletal rehabilitation

(arthritis, fibromyalgia, or back pain)

• Pain management

(chronic pain)

• Cardiac rehabilitation

(AMI, CABG’s, cardiomypopathies, stents, pacemaker, other acute events)

Outpatient programs

• Respiratory rehabilitation

(emphysema, chronic bronchitis, thoracic surgery or pneumonia)

• Sleep disorder

(Ax and Rx of breathing problems during sleep, insomnia or excessive sleepiness)

“SAFE WALKERS”Description and aims

Run under Neurology outpatient streamA comprehensive team approach for the assessment and

treatment of people who suffer from recurrent falls or poor balance affecting mobility and safety.

Aims to remediate and improve strength, fittness, balance, as well as retrain balance skills.

Educate and provide problem-solving sessions to minimise falls.

Use of safety strategies in various environments and situations.

Promote confidence and independence.

Rehabilitation Team

Safe Walkers treating team

Rehabilitation consultant

Physiotherapist Occupational Therapist

Dietician

PsychologistAllied Health Assistant

Referral sources & procedure

Referral sources GP’s Inpatient referrals

(Internal and other Acute private hospitals)

Specialist medical consultants

Community organisations

Referral procedure Referral from GP or

medical specialist required in writing

Health fund check Assessment by OT/PT Entry to program

Admission criteria

TARGET GROUPS

• History of falls

• General physical

deconditioning

• Reduced ability to cope

functionally

• Emotional/psychosocial

difficulties

• Fear of falling

NON-TARGET GROUPS

• Medically unstable

• Acute vestibular dysfunction

• Individuals with significant cognitive/memory deficits

• Inability to cope in a group setting

Assessment 1 ½ hour subjective/objective

assessment with physiotherapist and occupational therapist

Outcome measures (refer to table) Provision of information

/education booklet Home visit booked Scheduled to start program

MEDICAL REVIEW Consultants review half way

through program Team meeting with Consultant

and therapists fortnightly

Occupational

Therapist

Physiotherapist

Modified fear of falling scale

Smart balance master

Folstein mini mental

Timed up and go

Barthel ADL index

Step test

Goals 10 metre walk test

Home Assessment (as needed)

Functional reach

Balance Master

Group structure & content

Monday Tuesday Wednesday Thursday

9.30-10.30

OT Patient Assessment

OT Patient Assessment

10.00-10.45

PT Strength PT Strength PT Strength PT Strength

10.45-11.00

Morning tea

PT Patient

Assessment

Morning tea Morning tea

PT Patient

Assessment

Morning tea

11.00-11.45

Education Education Education Education

11.45-12.30

PT Balance

Exercises

PT Balance

Exercises

PT Balance

Exercises

PT Balance

Exercises

Treatment 6/52 program, twice a week sessions for 2 ½ hours Mondays/Wednesdays or Tuesdays/Thursdays (4/52 program for DVA)

• Balance retraining• Strengthening and stretching• General conditioning• Outdoor and community mobility retraining• Assessment and provision of appropriate gait aids• Education on falls prevention• Functional retraining: ADL• Home visit• Psychology assessment• Referral for community services

Balance exercises

Occupational Therapy: ADL training

EducationTOPICSBalanceCauses of fallsCommunity safetyHome safetyEnergy conservationWhat to do if you fallHome practicalWellbeingManaging fear of falling: RelaxationPutting changes in to practiceNutritionPreparation for outdoor walking* Outdoor walk & public transport access is conducted every 6/52, or 1:1

Outdoor mobility and public transport access

Evaluation

• On the patient’s final session the outcome measures are taken again

• Goals reviewed• Referral to a community exercise program

is arranged as appropriate• A 3 month review appointment is given• Discharge summary sent to GP and/or

referring specialist

Future direction with data collection• Recent development of new database 2005• Collecting following data using excel spreadsheet format:

Gender Step test (ADM,D/C,RV)

DOB Functional reach (ADM,D/C,RV)

Reason for referral Sit to stand (ADM,D/C,RV)

Primary presenting condition Fear of falling scale (ADM,D/C,RV)

Timed up and go (ADM,D/C,RV) Mini mental (ADM, D/C)

Functional reach (ADM, D/C,RV) Falls 3/12 prior to the program Smart balance master (ADM,.D/C, RV)Private rehab post program

10 metre walk (ADM,D/C, RV) Falls during program (+ 3/12 RV)

Psychology referral Community referral

Barthel ADL index (ADM,D/C)

Project Aims

to compare the efficacy of 4 week v 6 week program to evaluate the demographics of the patients referred to

the program, thus establishing target groups to assess the long term effectiveness of the program (3

month review) to identify and track the primary referral sources to increase suitability of referrals to determine the effectiveness of Cedar Court’s falls

and balance program both qualitatively and quantitatively

Project aims

Evaluating compliance by determining the percentage of patients completing the program

Look at trends with outcomes for different patient groups (considering diagnoses, age, gender, supports in place)

Provide insurance providers with evidence of program effectiveness (justification of program length, and disciplines needed)

Implementation of suggestions from patient feedback surveys

Methodology

Step 1- Identification of aims Step 2- Entering of data collected from the

past 6 months (n=50) Step 3- Evaluation and analysis of data Step 4- Presentation of data internally and

externally (Falls Clinic Coalition) Step 5- Implementation of findings

Limitations

No control groupIncomplete data e.g patient unable to do balance master

Extraneous variables e.g patient wearing different shoes on admission and discharge thus reducing reliability

Multifactorial problems

References

• Cockrell JR & Folstein (1988). Mini Mental Status Examination, Psychopharmacology, 24: 689-692

• Cole,B., Finch,E., Gowland,C., Mayo,N. Physical Rehabilitation outcome measures. Toronto: Canadian Physiotherapy Association, 1994

• Duncan,P., Weiner,K., Chandler,J. et al: Functional Reach: A new clinical measure of balance. Journal of Gerontology 1990; 45: M192-97

• Hill,K., Bernhardt,J., McGann,A. et al: A new test of dynamic standing balance for stroke patients: Reliability, validity, and comparison with healthy elderly. Physiotherapy Canada 1996; 257-62

• Mahoney FI, Barthel,D. “Functional evaluation: the Barthel Index” Maryland State Medical Journal 1965; 14: 56-61

• Podsiadlo,D., Richardson,S: The “timed up and go test”: A test of basic functional mobility for frail elderly persons. Journal of the American Geriatrics Society 1998;46: 758-61

• Tinetti,M., Richman, D., Powell,L. Falls efficacy as a measure of fear of falling. J Gerontology 1990; 45: P239-43