Advanced gait and balance technologies play a vital role in predicting and preventing falls
Strategies implemented to treat patients who have fallen or are at risk for a fall often stem from tried-and-true therapeutic rationale intended to address a far less lucid target: fear. The approaches and technologies used to predict and prevent a potential occurrence, or reoccurrence, of trauma can help derail this fear by educating and training the patient.
Developing a Game Plan
Predicting and preventing falls continues to be a focus of research, outcome measures, education, and healthcare costs nationwide, points out Stephanie Kaplan, PT, DPT, APT, director of rehabilitation at Casa Colina Hospital and Centers for Healthcare, Pomona, Calif. Additionally, each year one in every three adults aged 65 years or older falls, and 2 million are treated in emergency departments for fall-related injuries. The risk for falling also continues to climb with each decade of life.1
“Each year, one in every three adults aged 65 years or older falls, and 2 million are treated in emergency departments for fall-related injuries.”
Such statistics highlight the vital role physical therapists play in identifying, educating, and training patients in fall prevention. Kaplan adds that there are a variety of commonly used fall assessment scales at physical therapists’ fingertips, yet the challenge can be in selecting the tool most appropriate for the patient.
Several resources can assist in selecting the most appropriate tool for a patient, including rehabmeasures.org and the American Physical Therapy Association’s (APTA) Neurology Section EDGE documents at www.neuropt.org. Kaplan classifies both of these resources as critical to identifying outcome measures specific to a patient’s diagnosis and position in the continuum of care.
A comprehensive physical examination or physical therapy evaluation that takes into account medical history, home environment, strength, sensation, cognition, range of motion, daily activities, and exercise patterns completes the fall risk assessment. Additionally, the impact of aging, along with the variety of disease processes that can lead to increased fall risk, must be thoroughly understood by the therapist, explains Ben Gilbert, PT, MS, OCS, Cert MDT, manager, Outpatient Physical Therapy Department, Burke Rehabilitation Hospital, White Plains, NY.
“This should be combined with objective tests and measures that have been validated through research to predict fall risk, both in the home and community at large,” Gilbert says. The Berg Balance Scale, Timed Up and Go, and Dynamic Gait Index exemplify such tests.
He adds that blending “objective measures with a patient’s subjective and medical history gives a more thorough picture of a patient’s fall risk than either approach alone.”
Technologies and Tools
The market features an assortment of commercially available body weight support systems, built to assist with gait and balance and improve function. The Bioness Vector Gait and Safety System, available from Valencia, Calif-based Bioness, is an overground gait and body-weight support system designed to allow patients to engage in gait and balance activities in all planes of movement. Kaplan notes that the harness provides support to ensure patient safety, while also decreasing the physical assistance required of the therapist.
The staff of the Baton Rouge Rehab Physical Therapy Department at Baton Rouge Rehabilitation Hospital, La, classifies the Aretech ZeroG, from Aretech LLC, Ashburn, Va, and the Biodex Balance System SD, from Biodex Medical Systems Inc, Shirley, NY, as technologies that help them introduce increasingly challenging tasks to patients in a safe manner. Therapists at the facility report that many patients, especially those with poor insight into their deficits, benefit from the quantitative feedback provided by these systems.
Also among the latest body weight support systems on the market is the SafeGait 360° Balance and Mobility Trainer from Gorbel Medical, Fishers, NY, with Patient Management Software built to allow patient performance measures to be tracked and compared by task and session, the ceiling-mounted Solo-Step System by Sioux Falls, SD-based Solo-Step, and the Lokomat from Hocoma Inc, Norwell, Mass.
The Burke Rehabilitation Hospital Outpatient Physical Therapy department uses technologies such as body weight support harnesses, the Biodex Balance System SD, and the Wii video game console from Nintendo Co Ltd, Kyoto, Japan. Both the Biodex SD and the Wii video game console use force plates and video biofeedback. This allows for weight shifting, squatting, reaching, and leaning activities that can be practiced and improved.
“All levels of injury can be treated this way, from a golfer practicing his swing after a mild stroke, to a patient with Parkinson’s [disease] who needs to improve his functional mobility around the house. Patients enjoy the challenge of reaching targets and beating their score,” Gilbert points out. He notes that the body weight support harness, also made by Biodex, allows for walking on a treadmill, as well as walking overground.
AMTI, Watertown, Mass, also offers force plates for gait and balance, such as the AccuGait and AccuSway. GAITRite from CIR Systems Inc, Sparta, NJ, is a portable gait analysis system designed to help a clinician collect and analyze data and generate reports. The Zeno Walkway, featuring a 16-level pressure-sensing pad and circuitry from ProtoKinetics, Havertown, Pa, can also serve as a key player in assessing gait and balance. Walkway pressure mapping systems are also available through Tekscan, South Boston.
Strategy and Reward
Combining equipment that targets individualized strength and balance training with gait and balance technologies can help enhance rehabilitation.
While the Baton Rouge Rehab Physical Therapy Department offers an interdisciplinary fall prevention program, it also emphasizes a preference to an individualized course of treatment for its patients. In addition to the ZeroG, a range of neurorestorative techniques and “low-tech” tools used in this individualized course of treatment include Airex balance pads, BOSU balls from the Ashland, Ohio-based company BOSU, Dyna Disk, and rocker boards. Rocker boards are marketed by a variety of manufacturers, including SPRI Products, Libertyville, Ill, and Fitter International Inc (Fitterfirst), Calgary, Alberta, Canada. The NeuroCom SMART EquiTest from Natus Medical Inc, San Carlos, Calif, is another recommended product that can be used for balance assessment and retraining. The technology allows patients to test and train in environments that challenge their vestibular, somatosensory, and visual systems.
Equipment to Address Drop Foot Among Fall Patients
Ankle foot orthoses (AFOs) and functional electrical stimulation (FES) systems each play a role in compensating for weakness in patients who are at risk for falls and coping with drop foot.
“An AFO can be set up to compensate for weakness in the anterior tibialis
and gastroc/soleus complex. It is important to work with an experienced orthotist who has access to a wide variety of materials that will suit the patient’s needs. There is not a one-size-fits-all orthosis,” Kaplan advises. She adds that key factors in selecting an AFO include compliance, sensation, skin integrity, ankle stability, and proximal strength at the hip and knee.
AFOs, such as those in Rockaway, NJ-based Allard USA Inc’s ToeOff Family, work to accommodate a variety of conditions and stability needs. Orthoses in the line include the Ypsilon, designed to address mild to moderate drop foot. The company’s ToeOff/ToeOff 2.0 targets mild to severe drop foot accompanied by mild to moderate ankle stability, and the BlueRocker is engineered to provide multiple involvement ranging from drop foot, to severe ankle instability, and/or proximal neuromuscular weakness/deficits. AFOs are distributed and manufactured by other companies as well, including Germany-based Ottobock. Its WalkOn AFO is a lower-leg orthosis intended to help lift and support light to severe drop foot.
While trained on the same goal of improved function, Gilbert points out that FES systems differ from AFOs, PLS, KAFOS, and other lower-extremity bracing, which provide passive support to clear the foot during walking. FES systems target the promotion of muscle development, stimulating the muscles as the patients walk. The Bioness L300 and L300 Plus exemplify these systems, which are designed to use electric stimulation to help patients with drop foot walk more safely and effectively.
The Baton Rouge Rehab Physical Therapy Department also uses the Bioness L300 and L300 Plus, while continuing to use various carbon fiber AFOs and dynamic articulating AFOs.
Gilbert states, “Another gait and balance technology system we use is the WalkAide system, by Innovative Neurotronics [Austin, Texas]. This system also uses electric stimulation to help strengthen the muscles that are weak in drop foot and is also very effective.”
A Focused Future Without Fear
Whether high- or low-tech, in the hands of the physical therapist, these approaches and technological advances in gait and balance equipment help provide individualized care to patients who have fallen or are at risk for a fall, setting their course to recovery back on track. PTP
Brittan West is managing editor of Physical Therapy Products. For more information, contact [email protected].
1. Preventing falls among older adults. Retrieved from http://www.cdc.gov/Features/OlderAmericans/. Accessed December 9, 2014.