Fall Risk Reduction Program
Designing an Exercise Program
Module #3
Shelley Thomas, MPT, MBA
Dara Coburn, M.S., CCC-SLP
Fall Risk Reduction Program:
Review of Modules 1 & 2
 In the first module we reviewed the premise
of the Fall Risk Reduction Program, including
the inclusion criteria for patient selection
 The second module reviewed patient
assessment
 Identifying patients at risk of falling
 Evaluating patients in a dual task condition to
simulate “real life” situations
Fall Risk Reduction Program: Module 3
 In this module, we will delve further
into patient assessment. You have
identified patients at risk for falling
and evaluated performance under
dual task conditions. Now you must
further do further assessment to
identify the system(s) of balance most responsible for the
falls, and develop an plan of care to address the system(s).
 Agenda
 Screening & Assessing Balance Impairments: Information to
gather in order to design an exercise program
 Exercise selection
 Designing a program
Agenda
 Screening & Assessing Balance
Impairments: Information to gather in
order to design an exercise program
 Exercise selection
 Designing a program
Multifactorial Risk Assessment
Focused History
Physical Examination
Functional Assessment
Environmental Assessment
American Geriatric Society Clinical Practice Guidelines: Prevention of
Falls in Older Adults
Multifactorial Risk Assessment:
Focused History
 History of falls – need detailed
description of the fall circumstances,
frequency, symptoms
 Medication review
 History of risk factors – acute & chronic
medical issues
Multifactorial Risk Assessment –
Physical Exam
 Physical function - Gait, balance (including postural reflexes),
mobility, and lower extremity joint function
 Neurological function – Cognitive evaluation, peripheral
nerve function, proprioception, reflexes, and tests of cortical,
cerebellar, & extrapyramidal function
 Muscle strength
 Cardiovascular status – Heart rate, postural pulse, blood
pressure
 Visual acuity
 Vestibular function (oculomotor tests, positional testing)
 Examine feet and footwear
Multifactorial Risk Assessment –
Functional Assessment
Assess activity of daily
living (ADL) skills
Perceived functional
ability and fear of falling
Multifactorial Risk Assessment –
Environmental Assessment
Home safety
Other environment
factors as needed
Turning the multifactorial risk
assessment into an exercise
program – What to do with all
this information?
Stratify the Patient Problems into
Systems of Balance
 Musculoskeletal System
 Proprioceptive System
 Oculomotor System
 Vestibular System
 Cognition/Communication
Musculoskeletal System
 Muscle, tendons, ligaments, bones, joints, and
associated tissues that move the body and maintain
form
 Key muscle groups associated with walking and
upright balance reactions:
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Hip flexors
Hip extensors (especially gluteous maximus)
Hip Abductors (especially gluteous medius)
Knee extensors (quadricepts
Knee flexors (hamstrings)
Plantarflexors (gastrocnemius, soleus)
Dorsiflexors
Upper and lower abdominal muscles
Proprioceptive System
 Proprioception is the
unconscious awareness
of body position.
 It tells us about the position of our body parts
in relationship to each other and the
environment.
 It allows us to have a knowledge of how much
force and speed the muscle is required to
generate in order to accomplish a specific
movement which results in appropriately
graded muscle control.
Oculomotor System
 Is the control system that coordinates
the 12 muscles which accurately direct
our eye movements.
 Three main types of Oculomotor Skills:
 Saccades – The ability to quickly and
accurately make eye movements or jumps
from one target to another.
 Fixation – The ability to maintain steady
visual attention on a target.
 Pursuits – The ability to smoothly follow a
moving target.
Vestibular System
 System of the body
that is responsible for
spatial orientation and
balance.
 The vestibular system sends
information to the brain about
the location of one's head in
space.
Vestibular, Oculomotor, Proprioception
Systems: Need at least two
 In order to maintain balance, at least two of
these systems must be sending balance
information to the brain at any time.
 Examples:
 If in the dark, brain can use proprioceptive and
vestibular inforamation to remain upright against
gravity.
 If have lower extremity amputation, can use
vestibular and oculomotor systems.
 If have labrynthiasis impacting vestibular system,
can use oculomotor and proprioceptive
information.
Cognition & Communication Systems
(involved in dual tasking)
 Cognition is the ability to think and process information
 Attention, memory, processing, problem solving, judgment, impulse
control, and executive skills.
 Communication is the ability to exchange and comprehend
language.
 Naming, word finding, following directions, answering questions,
speaking, and writing.
 How much of the “cognitive pie” does mobility take? If
maintain balance “hogs” resources, decreases cognitive and
communication skills.
 Places person in an either/or situation – can maintain balance or focus
on cognitive task.
Sample Patient Problem List
Musculoskeletal
Peripheral Neuropathy
Proprioception
Oculomotor
Vestibular
X
Lower extremity
strength rated 3/5
X
Flexed posture
X
Inadequate footwear
X
X
X
Decreased visual acuity
due to diabetic
retinopathy
X
Decreased problem
solving skills
Impaired balance
reactions
Cognition
X
X
X
X
Now that you have stratified the
problems into the systems of
balance, you can design a plan
of care that incorporates
Interactive Metronome
Why include Interactive Metronome in
the plan of care?
 Movement Requires Directed attention
 Pathologies that disrupt motor timing and sequencing lead to
inaccurate movements
 IM & Dual Tasking
 IM requires a patient to focus on auditory stimuli and make a
motor response to hit the trigger on the beat.
 Must decide if need to slow down, speed up, or remain
consistent.
 Computer can measure performance in milliseconds, so act at
same speed as muscular contractions.
 Helps patients identify their own timing tendency and learn how
to counteract own tendencies.
Fall Risk Reduction Program Exercises
 This library of exercises are
suggestions. Concept is to design
exercises, using the Interactive
Metronome that target specific
problem areas
 Center treatment interventions
around long and short term goals
that are important to the patient.
Goal selection was discussed in the
second module
 Download can be found on course
materials page
Musculoskeletal System Exercises
*Photos and exercise descriptions available on course materials page
Leg Squats
Alternate Stepping
Lunges
Stepper with Weights
Heel Raises
Bridging
Long Arc Quads
Abdominal Crunch
Taps Ups
Postural Alignment
Lateral Tap Ups
Postural Alignment with Marching
Proprioceptive System Exercises
*Photos and exercise descriptions available on course materials page
Clock
Clapping with Eyes Closed, Seated
Uneven Surface with Eyes Open
Clapping with Eyes Closed, Standing
Uneven Surface with Eyes Closed
Oculomotor System Exercises
*Photos and exercise descriptions available on course materials page
UNO Poster Board
Visual Sequencing
Visual Memory
Recall/recognition
Vestibular System Exercises
*Photos and exercise descriptions available on course materials page
Head Movement in Supine
Sidelying to Sit with Head Rotation
Head Movement in Sitting
Visual tracking focal item
Head Turns with Reaching Across Midline
In Sitting, Head stationary, Saccades
Head Turns with Walking
Using the in-Motion Triggers
Rolling
Seated, Reaching Across and Behind to hit target
Cognition/Communication System Exercises
*Photos and exercise descriptions available on course materials page
STROOP Activities
Yes/No Questions
Selected and Divided Attention
Aphabetizing
Naming
Visual Attention
Sorting
Word Finding
Memory
Sequencing
Melodic Intonation
Picture Identification
Impulse Control
Intelligibility Drills
Following Directions
Safety Awareness
Oral Motor Exercises
Setting Table
Fall Risk Reduction Poster
Overview
Fall Risk Reduction Best Practices Kit
 Contains:
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1 – STOOP Board (12” x 18”)
5 – Fill-in-the-Blank Cards (4” x 11”)
5 – Melodic Intonation Cards (4” x 11”)
15 –Object Cards (7½” x 6”)
1 set – 1 – 12 Numbered Cards (8½” x 4”)
1 set – Yes/No Cards (4” x 8½”)
1 set – 1 – 25 Numbered Cards (4” x 3”)
15 – Word Cards (2½” x 3)
1 set – Various Sized Squares
Integrating Kit Items for Fall Risk
Reduction Tasks
1 – 12
Numbered
Cards
Toe Tapping Clock
Various
Sized
Squares
Object
Cards
Visual Memory
Memory
Naming
Picture Identification
1 – 25
Numbered
Cards
STOOP
Board
Word
Cards
STROOP Activities
Alphabetizing
Yes/No
Cards
Fill-in-theBlank Cards
Melodic
Intonation
Cards
Sorting
Sequencing
Yes/No Questions
Word Finding
Melodic Intonation
"Homework"
Complete following worksheet to
develop a plan of care for your
patient. Use the same patient as in
Module #2.
Post-test
Complete post-test to receive link
for Module # 4 of 6
Materials Page
 This video
 PowerPoint
 Module 3 Homework
 Exercise Guide
 Poster
 Best Practices Kit
 www.interactivemetronome.com/index.php/
fall-risk-coaching
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