Using the Guide to Physical Therapist Practice
as a map in the Management of
Elderly Balance and Mobility Dysfunction
This course will review the examination and intervention for those older adults with
balance impairments as outlined within the Guide to Physical Therapist Practice. It will
focus upon a continuum of decision-making and discuss how the clinical management
might change when considering impairments without pathology versus clients with
various types of functional limitations following neurological insult.
Darcy Umphred, PhD, PT
Marcia Hall, PT
Objectives:
At the conclusion of this presentation, participants will:
 Analyze the "Guide" as a tool to help map his or her clinical decision-making when
evaluating and establishing intervention with clients who are falling or have balance
impairments.
 Identify accurate practice patterns, analyze examination and best practice
intervention options when considering various types of balance impairments, with
and without identifiable disease.
 Understand the health economics of intervention through successful application of
the “Guide” in the aged population.
Course Outline:
1. Introduction
2. The Need: "Guided" intervention in the management of elderly balance and mobility
impairments.
a. Aging demographics- the scope of the need
b. Impairments of Posture and Balance related to aging
• Peripheral Impairments
— Musculoskeletal
— Sensory
• Central Impairments
— Sensory integration
— Motor control
— Affective
NOTES:
Management of Elderly Balance and Mobility Dysfunction
Umphred and Hall
1 of 5
c. Introduction and importance of the Preferred Practice Pattern: Primary
Prevention/Risk Reduction for the Loss of Balance and Falling
NOTES:
3. The Problem: Elderly Mobility related to Posture and Balance Dysfunction
a. No identified pathology/ no functional limitations
b. No identified pathology/ present functional limitations
c. Medically diagnosed pathology/ present functional limitations
NOTES:
4. The Challenge: Factor Identification
a. Modifiable
b. Non-modifiable
NOTES:
5. The Examination: Selection and identification of critical elements for intervention
design (evaluation)
a. Purpose
b. Diagnosis/Prognosis (Use of the Guide)
c. Relationship to elderly mobility problems (#3 above)
d. Integration of impairment information and medical diagnosis information
e. "Guided" approach vs. traditional approaches
• Specific test and measurement options
• Clinical problem solving: Systems interaction vs. a linear approach
Management of Elderly Balance and Mobility Dysfunction
Umphred and Hall
2 of 5
NOTES:
6. The Intervention: Selection
a. Pathology vs. Impairment (Disability) driven
b. Interaction of Prognosis and Intervention
• External Limitations
• Internal Limitations
c. Strengths and Limitations of the Guide
NOTES:
7. The Application: Case Presentations
NOTES:
8. Summary
NOTES:
Management of Elderly Balance and Mobility Dysfunction
Umphred and Hall
3 of 5
References:
Alexander NB, et al. “Postural control in older adults.” J Am Geriatr Soc. 1994; 42: 93-108.
Beckley DJ, et al. “Impaired scaling of long latency postural reflexes in patients with Parkinson's disease.”
Electroencephalogr Clin Neurophysiol 1993; 83:22.
Bloem BR, et al. “Altered postural reflexes in Parkinson’s disease. A reverse hypothesis.” Medical Hypotheses 1992;
39:243-247.
Bloem BR, et al. “Influence of dopaminergic medication on automatic postural responses and balance impairment in
Parkinson’s disease.” Mov Disord 1996; 11:509-521.
Bond JM, Morris ME. “Goal-directed secondary motor tasks: their effects on gait in subjects with Parkinson’s disease.”
Arch Phys Med Rehab 2000; 81:110.
Brown J, et al. “How the basal ganglia use parallel excitatory and inhibitory learning pathways to selectively respond to
unexpected rewarding cues.” J Neurosci 1999; 19:10502-10511.
Camicioli R, et al. “Balance in the Healthy Elderly: Posturography and Clinical Assessment.” Arch Neurol/Vol 54, Aug
1997.
Ellen Fruedenhiem, editor. Chronic Care in America: A 21st Century Challenge. The Robert Wood Johnson
Foundation, Princeton, 1996.
Conner NP, Abbs JH: “Task-dependent variations in Parkinsonian motor impairments.” Brain 1991; 114:321.
Dalen J, editor. “Health Care in America: The Good, the Bad, and the Ugly.” Archives of Int Med; Vol 160: Sept 25,
2000.
Daley K, et al. “Reliability of scores on the stroke rehabilitation assessment of movement (STREAM) measure.” Phys
Ther 1999; 79:8.
Diener HC, Dichgans J. “Cerebellar and spinocerebellar gait disorders.” In Bronstein AM, Brandt T, Woollacott M,
editors: Clinical disorders of balance, posture and gait, London, 1996; Arnold, pp. 147-155.
Elmore J, et al. “Assessing the Accuracy of Diagnostic and Screening Tests, in Evidence-Based Clinical Practice:
Concepts and Approaches.” Geyman ed; Butterworth Heinemann, Boston, 2000.
Functional Independence Measure. Guide for the Uniform Data Set for Medical Rehabilitation (Adult FIM) Version 5.0
Buffalo, NY 14214, State University of New York at Buffalo, 1996.
Gowland C, et al. “Measuring physical impairment and disability with the Chedoke-McMaster Stroke Assessment.”
Stroke 1993; 24:58.
Gregson JM, et al. “Reliability of the Tone Assessment Scale and the modified Ashworth scale as clinical tools for
assessing poststroke spasticity.” Arch Phys Med Rehabil 1999; 80:1013.
Herdman S, et al. “Falls in Patients with Vestibular Deficits.” Am J of Otology; 2000; 21: 847-851
Horak FB, et al. “Postural instability in Parkinson's disease: motor coordination and sensory organization.” Anaheim,
1984, Society for Neuroscience Abstract.
Horak FB, Nutt JG, Nashner LM. “Postural inflexibility in parkinsonian patients.” J Neurol Sci. 1992; 111:46-58.
Jobst, et al. “Sensory perception in Parkinson’s disease.” Arch Neurol 1997; 54:450.
Jog MS, et al. Building neural representations of habits. Sci 1999; 286:1745.
Juneja G, et al. “Admission balance and outcomes of patients admitted for acute inpatient rehabilitation.” Am J Phys
Med Rehabil 1998; 77:388.
Karlsen K, et al. “Fatigue in patients with Parkinson’s disease.” Mov Disord 1999; 14:237.
Kopp B, et al. “The Arm Motor Ability Test: reliability, validity, and sensitivity to change of an instrument for assessing
disabilities in activities of daily living.” Arch Phys Med Rehabil 1997; 78:615.
Lajoie Y, et al. “Upright standing and gait: are there changes in attentional requirements related to normal aging.”
Exp Aging Res 1996; 22: 185-198.
Lauk M, Chow CC, Lipsitz LA, Mitchell SL, Collins JJ: “Assessing muscle stiffness from quiet stance in Parkinson's
disease.” Muscle Nerve 1999; 22(5):635-639.
Management of Elderly Balance and Mobility Dysfunction
Umphred and Hall
4 of 5
Marshall SC, et al. “Validity of the PULSES profile compared with the Functional Independence Measure for
measuring disability in a stroke rehabilitation setting.” Arch Phys Med Rehabil 1999; 80:760.
McIntosh GC, et al. “Rhythmic auditory-motor facilitation of gait patterns in patients with Parkinson’s disease.” J.
Neurol Neurosurg Psychiatry 1997; 62:22.
McPherson D, et al. “Disequilibrium of Aging” In Goebel, J ed; Practical Management of the Dizzy Patient; Williams
and Wilkins, 2000.
Melnick M, et al. “The effect of rhythmic exercise on gait, balance and depression in people with Parkinson’s
disesase.” J Am Geriatr Soc, 1999; 47.
Mngoma NF, et al. “Resistance to passive shoulder external rotation in persons with hemiplegia: evaluation of an
assessment system.” Arch Phys Med Rehabil 1999; 80:531.
Morris ME, Lansek R. “Characteristics of motor disturbance in Parkinson’s disease and strategies for movement
rehabilitation.” J Hum Mov Sci 1996.
Newton RA. “Balance screening of an inner city older adult population.” Arch PM&R 1997; 78:587-591.
Patti F, et al. “Effects of rehabilitation therapy on Parkinsonian’s disability and functional independence.” J Neuro
Rehab 1996; 10:223.
Powell LE, Myers AM. “The activities-specific balance confidence (ABC) scale.” J Gerontol 1995; 50A(1):M28,.
Province MA, Hadley EC, Hornbrook MC, Lipsitz LA, Miller JP, Mulrow CD, Ory MG, Sattin RW, Tinetti ME, Wolf SL. “The
effects of exercise on falls in elderly patients. A preplanned meta-analysis of the FICSIT Trials.” Frailty and Injuries:
Cooperative Studies of Intervention Techniques. JAMA May 1995; 273 (17): 1341-1347.
Rijntjes M, Dettmers C, Buchel C, Kiebel S, Frackowiak RSJ & Weiller C. “A blueprint for movement: functional and
anatomical representations in the human motor system.” J of Neuroscience 1999; 19(18):8043-8048.
Rose DJ, et al. “Can the Control of Bodily Orientation be Significantly Improved in a Group of Older Adults with a
History of Falls?” JAGS 2000; 48: 275-282.
Roth EJ, et al. “Impairment and disability: their relation during stroke rehabilitation.” Arch Phys Med Rehabil 1998;
79:329.
Sattin R, et al. “Falls among older persons: a public health perspective.” Annu Rev Public Health 1992; 13: 489-508.
Schenkman M, et al. “Exercise to improve spinal flexibility and function for people with Parkinson’s disease: a
randomized, controlled trial.” J Am Geriatr Soc 1998; 46: 1207.
Schrodt L, et al. “Dual-Task Performance of Cognitive and Balance Tasks in Older Adults.” APTA Issues on Aging 2000;
Vol 23: 3.
Schumway-Cook A, et al. “Measuring Fall Risk in Elders: Theory and Practice.” February 2000 APTA Combined
Sections Meeting; Neurology and Geriatric Section Compendiums.
Shepard N, et al. “Practical management of the balance disorder patient.” Singular Publishing Group, Inc, 1996, San
Diego.
Smithson F, et al. “Performance on clinical tests of balance in Parkinson’s disease.” Phys Ther 1998; 78:577.
Thaut MH, et al. “Velocity modulation and rhythmic synchronization of gait in Huntington’s disease.” Mov Disord
1999; 14:808.
Tinetti, et al. “Risk factors for falls among elderly persons living in the community.” N Engl J Med 1988; 319: 1701-7.
Tinetti, et al. “Dizziness among older adults: a possible geriatric syndrome.” Annals of Internal Med 2000; 132: 337344.
Turner-Stokes L, et al. “The UK FIM+FAM: development and evaluation. Functional Assessment Measure.” Clin
Rehabil 1999; 13:277.
Umphred D. “Neurological Rehabilitation 4th edition.” Harcourt Health Science, Philadelphia, March 2001.
Wallman K, et al. “Older Americans 2000: Key Indicators of Well-Being.” Federal Interagency Forum on Aging
Related Statistics; Aug 2000.
Whipple R, et al. “The Relationship of Knee and Ankle Weakness to Falls in Nursing Home Residents: An Isokinetic
Study.” JAGS 1987; 35:13-20.
Management of Elderly Balance and Mobility Dysfunction
Umphred and Hall
5 of 5