foreseeable disturbances: an innovative clinical perspective

foreseeable disturbances: an innovative clinical perspective -

INTRODUCTION

falls are the leading cause of nonfatal injuries and injury deaths in the United States, representing approximately 48% to 75% of all unintentional injuries reported for adults 65 years and older ¹ with a hip fracture incidence should risedue to the growth of the elderly population ²

. Most falls occur in or outside the house ³ resulting from the strength and mobility of persistent deficits that contribute to the decline in the balance, limiting the ability of independent function and further increasing the risk of recurrent injury. ⁴

fall risk depends on the interaction of many factors, and falls are particularly difficult to explain in the elderly who live an active and independent life. ⁵ Current tests are less able to explain the falls in active older adults than those described as frail.5 Timed mobility performance measures may not challenge adequately systems to detect key issues in fall risk situations in people having no deficits in the existing balance or display outward observable limits. ^{6, 7} The inability to balance and timed mobility performance measures to explain the fall is partly due to intrinsic ceiling effects, compromised the sensitivity associated with a lack of variability in the maximum scores performance and their lack of responsiveness to falls in active adults living in the aging community. ^{5, 8, 9} of new evaluation tools are required for a population of active aging. These tools should include measures based on the most difficult performance 5, including situations requiring reagents balance.10 researchers must test individuals as they react to external perturbations requirements. ¹⁰ Following a disturbance that could cause a fall, it must recover balance using a response strategy postural feet up, or protection compensation step. ¹¹

assessment and treatment paradigms disturbance attracted recent attention. ^{9.12 to 15} Designed with a reactive way in an attempt to mimic "real life" circumstances, the disruption of studies do not provide objective performance measures or step quantitative or procedures are clinically safe or practical use in multiple clinical settings.

The use of a foreseeable disruption assessment paradigm is supported by studies finding that the predictability and prior knowledge of the magnitude and direction of the perturbing forces do not alter the EMG latency motor responses of the lower limbs and have no effect on automatic postural responses. ^16.17 A valid predictable perturbation method, reliable, convenient, safe and clinically feasible (ICC = 0.94, ROC AUC = 0.992, sensitivity = 93%, specificity = 96.6%), has been described. ¹⁸

disturbance neurophysiology

predictable Scaling

people without neurological impairment scale in proportion to the extent of their automatic postural responses to the extent of their imbalance ¹⁹ . This scaling is based on direct sensory characteristics, such as initial rate of perturbation and anticipatory mechanisms based on the prediction of movement characteristics, such as amplitude of the estimated displacement ¹⁹ . The nervous system must be based on predictive mechanisms based on past experience

Replies :.

proactive and reactive proactive and reactive adaptations each have an important role in preventing falls. reactive adaptations can reduce the probability of a loss of balance will lead to lower, while proactive adjustments may eliminate the occurrence of a loss of balance altogether. ¹⁹ proactive adaptations can be very effective when management of disruption is predictable and can lead to undesirable movement patterns that maintain the balance in both disturbed and undisturbed conditions. ¹⁹ When the disturbances are less certain, reactive responses can play the dominant role to prevent a fall. So it can be argued that adjustments both proactive and reactive should be targeted in interventions to reduce the incidence of falls in the elderly. Proactive adaptation to the stability of movement is a first line of defense against falls, while the reactive responses are a second line of defense; both are important. ²⁰ Adaptive control of feed-forward stability is based on an internal model continuously updated COG appears to be used by young and old. ²⁰ Both proactive and reactive mechanisms are routinely used to control balance while walking, models organized in the center of muscle activity, and modulated based on information available sensory, biomechanical constraints, support surface conditions and objectives of behavioral and learning. ¹² anticipation mechanisms are based on a feed-forward motion plane used in predictable situations well learned, while reactive mechanisms are generated by the use of sensorimotor feedback used in unpredictable situations. ¹² Reactive postural control can be used to modify the movements already underway and can be either automatic (reflexive) trip, or volition in case a correction on its own feet placement initiative. ¹²

Feasible Region stability

With repeated disruptions posture, the CNS probably built new, or updates to existing internal representations to improve its control feed -forward while reducing the dependence of a person on the feedback correction mechanisms for recovery. ¹⁴ the relationship between the center of mass of a standing person (COM) and the support base (BOS) defines the limits of stability, which describes a "stable region". The BOS consists of the bounding box of each leg in contact with the ground and the area between the feet biped position. a related increase in body sway age is often cited as an indication of a decrease in stability, and has been associated with the decline in the elderly. However, no conclusive evidence indicates that people swaying with greater amplitude are less likely to regain balance after disturbance. ¹⁴ a possible stability region (FSR ) between the front and back of the loss of balance thresholds. ¹⁴ loss of balance occurs when a large-scale disturbance moves the COM state outside the FSR than in instead of hip strategies resulting in an ankle and compensation step and establishing a new BOS. ¹⁴ Unfazed locomotion is a series of volitional controlled before falling constantly need not advance step. ¹⁴

Plasticity

neuromuscular mechanisms of protection against falls can be developed or improved with appropriate adaptation training. With repeated exposure to disturbances, a newly acquired form, primarily predictive adaptive control emerges with a reduced dependence on the feedback correction mechanisms for recovery. ¹⁴ The CNS built, refines and updates an internal representation of potential threats that may occur in the environment. ¹⁴

detention

retention in the CNS is generally regarded as a function of long-term changes that occur in the neural circuits, a result of the consolidation process or to the stabilization of long term memory. This process supports the formation of new synapses, the synthesis of new protein and increase in strength of existing synapses in cortical and subcortical structures (basal ganglia, cerebellum) for tasks involving voluntary movements. ¹⁴ The retention of adaptive behavior can be conditioned by the sanctions imposed inappropriate response by the NSC and the potential for increased injuries. A very threatening environment would be sufficient to induce long-term retention of acquired motor behavior. New evidence supports applying disturbance mimicking real life situations as a form of motor training, with long-term effects on postural stability for the prevention of loss of balance and falls. ¹⁴ Seniors can quickly develop coping skills for fall prevention in a similar way as young adults. ¹⁴

The main advantage of the training on the disturbance-base is a reduction in the travel time, rather than the time required to detect instability and initiate the response. ¹⁵

repeated incremental foreseeable disturbances in permanent: RIPPS

Overview

According to a recent study ¹⁸ The test spring Scale (ESS): a reliable and Tool available to explain fall History , a clinically practical method of perturbation, are predictable. Based on additional foreseeable disturbances repeated in standing (RIPPS) RIPPS the method is a first attempt, the single failure protocol clinically developed to quantify the forward and not back no limits with applications such as assessment and paradigm treatment-induced growth. Designed with a means of feed-forward, the RIPPS method is both reactive and proactive, consisting of repeated cycles of plane forces loading and unloading progressive sagittal to emphasize the boundaries of the front and rear not to not postural responses. Starting at 1 pound size tensile force, each tower loading and unloading is increased by 1 extra pound limits of postural stability RIPPS determined by performance criteria. limits step forward and rear directional are quantified as a percentage of total body weight (TBW%) for purposes of documentation fall risk assessment and responses to increase the limit induced formation. Using% TBW to quantify the disturbance force is well established. ^{10-15, 18}

Instrumentation and Control

Disturbance forces are quantified by a linear spring pocket scale strain gauge calibrated in increments of 1 pound, is fixed to a large 5 inches padded belt fixed around the waist of the customer and connected to the examiner by a strap length of security of attachment of 4 feet. Disturbances are administered with the examiner positioned close to the customer, standing about 3 feet of a conformal support surface. Anterior direction limit test (step back) is performed with the examiner to the customer, while the posterior direction of test limit (forward stepwise) is performed with the client back to the examiner.

RIPPS Disruption Method

Loading traction belt forces are administered in a predictable, progressive, fresh, accommodative mode. Customers are continuously charged to withstand loading forces to their maximum and are reminded RIPPS the performance criteria.

Unloading occurs at every turn 1 pound extra load force housed progressive. Unloading is administered quasi-random manner in a counting window of 5, at the discretion of the examiner. Clients are constantly reminded unloading performance criteria RIPPS

RIPPS performance criteria

RIPPS loading forces must be accompanied by a flat or low heel -. single contact floor postural response, defined as accommodation. RIPPS unloading postural responses should not exceed a 3 step response.

End Points RIPPS

One final point RIPPS occurs when loading or unloading RIPPS performance criteria are not met for a tour given size value of the traction force.

RIPPS limit Directional Score

A RIPPS TBW% directional limit score is obtained for both anterior and posterior directions. A directional force limit value is derived from the previous round to the directional endpoint strength (failure) round. The directional limit TBW% score is calculated by dividing the scale of the spring measured the strength in pounds by the weight of the client's body.

RIPPS TBW% Performance Measurement

The lowest directional scores 2% TBW limit is the% Performance RIPPS TBW measurement of clinical significance.

RIPPS Clinical Applications

assessment

RIPPS the method is a specific area for up and strengthening postural responses.

10% of the value of the performance is very TBW RIPPS discrimiant fall state providing clinicians a fall risk screening tool very sensitive and specific identity capable of deficits that would otherwise be missed in the vibrant and active community of older adults. The% TBW RIPPS performance measure should guide the functional locomotion recommendations, objectives and treatment interventions, where stepper limit induced deficits are identified. The 10% of the RIPPS TBW value should be considered a minimum threshold performance value compatible with non-fallers known about the age of 65 with an average of 12.3% TBW ¹⁸ suggesting a step function "reserve" exists and could be feasible and should be a clinical result in special treatment from the age group 80-89 represents the largest sample subgroup in the study SST.

Despite the predictability, anticipatory design RIPPS method, reactive postural reactions are typical, dominating the anticipated postural responses in those individuals with compromised balance reflected apprehension, hip strategy excessive load, several steps in response to unloading and excessive upper end answers. Ceiling effects rarely occur using RIPPS evaluation method.

Induced Stepping treatment Paradigm

induced stepping was associated with greater retention of skills. ¹⁴

The RIPPS method offers a safe option for the formation of induced step for those 65 and older, requiring intervention has reached a RIPPS% or less TBW score to 10%, meeting the lower RIPPS directional limit score% of TBW. Once% deficit limit directional step RIPPS TBW was identified RIPPS induced formation stage would involve repeated cycles of blocks of loading and unloading at the waist progressive traction forces. Anecdotal evidence suggests that sustained% TBW values ​​equal to or greater than 10% over a period of 2 weeks for 3 consecutive treatment sessions may suggest the retention of newly acquired skills step by step. Further study is warranted to examine training protocols and acquisition of long-term skills and fall state. Handling of feed-forward and reactive responses would be possible by load disturbance changes / unloading strength intervals. -Gué Not training options are possible using sustained, continuous loading the foot flat housing limits to increase the scale or strategies ankle and hip stabilization. methods of lateral disturbance (feet up and stepping induced) can also provide evaluation measures and clinical training options.

Summary

The purpose is to introduce RIPPS percent of total body weight (TBW%) as a measure of clinical practice to balance evaluation purposes and treatment for fall risk. Research supports the reliability and discriminant validity of the 10% of the value of the performance of TBW RIPPS to explain the fall in the history of independent community active life of the elderly.

1. Centers for Disease Control Web site. Available at: http://www.cdc.gov/ncipc/factsheets/adultfalls.htm . Accessed July 30, 08.
2. Cumming RG, Nevitt MC, Cummings SR. Epidemiology of hip fractures. Epidemiol Rev. 1997; 19 :. 244-257
3. Arnold CM, Faulkner RA. The fall of history and the combination of timed test and going to fall and almost falls in older people with osteoarthritis. BMC Geriatr. 07; 7:17 (9 pages).
4. Binder EF, Brown M, Sinacore DR, Stega May K, et al. Effects of extended outpatient rehabilitation after hip fracture: a randomized controlled trial. JAMA . 04; 18 :. 837-846
5. Boulgarides LK, McGinty SM, Justice Willett, Barnes CW. Use of clinical tests and on the basis depreciation predict falls among seniors living in the community. Phys Ther . 03; 83: 328-339
6. Thrane G, Joakimsen RM, Thornquist E. The association between timed and go test and history of falls: The Tromso study. BMC Geriatr . 07; 7: 1 (7 pages)
7. E Nordin, Lidelof N, Rosendahl E, Jensen J, Lundin-Olsson, L. Prognostic validity of the timed test up-and-go, a modified version of get-up-and -go test, global judgment of personnel and fall history in assessing the risk of falls in residential care facilities. Age Ageing. 08; 37 :. 442-448
8. MR Lin, Hwang HF, MH Hu, Wu HD, Wang YW, Huang FC. Psychometric Comparisons of the timed "up and go", stand on one foot, the functional scope and Tinetti balance measurements in the community-dwelling elderly. J Am Geriatr Soc . 04; 52: 1343-1348
9. Pai YC, Wang E, D Espy, Bhatt T. Adaptability to disturbances as a predictor of future falls :. A preliminary prospective study. J Geriatr Phys Ther. 2010; 33 (2) 50-61.
10. Harris JE, Eng JJ, Marigold DS, Tokuno CD, CL Louis. the balance of relationship and mobility in the fall incidence in persons suffering chronic stroke. Phys Ther. 05; 85 :. 150-158
11. Schultz BW Ashton-Miller JA, Alexander NB. compensatory stepping in response to the size draws women to balance drunk and impaired driving. Gait Posture. 05; 22 :. 198-209
12. Tseng S, et al. adjustments unreactive impaired in the elderly. J Gerontol A Bio Sci Med Sci . 09; 64a: (7). 807-815
13. A Mansfield et al. Effect of a balance training program based on the disturbance compensation approach and handle responses in the elderly: A randomized controlled trial. Phys Ther . 2010; 0: (4). 476-91
14. Pai YC, sliding training Bhatt T. Rpeated: A new paradigm for prevention of slip-related falls among the elderly. Phys Ther . 07; 87 :. (11) 1-13
15. Mansfield A, Peters G, Liu BA, BE Maki. A balance training program-based disruption for the elderly: study protocol for a randomized controlled trial. BMC Geriatr . 07; 7: 12 (17 pages)
16. Badke MB, Duncan PW, DiFabio RP .. Influence of prior knowledge on automatic postural adjustments and volunteers in healthy subjects and hemiplegic. Phys Ther. 1987; 67: 1495-1500
17. Diener HC, Horak F, Stelmach G, et al .. Management and precuing amplitude has no effect on automatic postural responses. Exp Brain Res . 1991; 89 :. 219-223
18. DePasquale L Toscano, L. The test in spring scale: A reliable and valid to explain the history of the fall. J Phys Ther Geratr ., 09; 32 (4) :. 159-167
19. Pavol MJ, Runtz EF, Pai YC. young adults and older have proactive and reactive adaptations to repeated exposure slip. Jl Gerontol . 04; 59 (5): 494-502
20. Pai YC, Wening JD, Runtz EF, Iqbal K, Pavol MJ ​​.. Role of pre-control movement stability by reducing the loss of slip-related balance and falls in the elderly. J Neurophysiol .03; 0: 755-762 ..

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Louis DePasquale PT, MA

Master of Arts Kinesiology, University of New York
physical Therapy certificate, Columbia University
BS physical Education, Manhattan College

Affiliations:
Good health system Relief term program Francis Schervier long Home health
Hebrew Home at Riverdale health Program Home long-term

Practice:
setting 30 geriatric home care

Publications:
• DePasquale L, L. Toscano "the test of the spring scale (ESS) A reliable and valid to explain autumn Story." JGPT 09; . 32 (4)
• R Bohannon, DePasquale L. "Operation of the physical scale of the Short-Form (SF) 36 :. internal consistency and validity with the elderly "JGPT 2010. 33 (1)
• DePasquale L," Disturbance neurophysiology. " Advance: for Physical Therapy and Rehabilitation Medicine 2011: October 17.
• DePasquale L, "Security in the balance" Physical Therapy Products November 2011.

Latest posts Louis DePasquale PT, MA (see all)

• preventing falls: current Perspectives, Tools with evidence - April 1, 2014
• performance measures: Does the performance Really Measure Up - April 1 2014
• foreseeable disturbances :? an innovative clinically - September 30, 08