CTSIB and Balance Impairments

CTSIB and Visual Impairment

• Conditions 4, 5, and 6 of the CTSIB will be especially difficult for visually impaired patients because they involve balancing on a foam pad.

CTSIB with Peripheral Neuropathy or Bilateral Vestibular Loss

• Patients with peripheral neuropathy will struggle with condition 2 (eyes closed on firm surface), condition 3 (visual conflict on firm surface), condition 5 (eyes closed on foam surface), and condition 6 (visual conflict on foam surface).
• Those with bilateral vestibular loss struggle with conditions 4 (eye open on firm surface), condition 5 (eyes closed on foam surface), and condition 6 (visual conflict on foam surface).

Postural Control Model Assessment Categories

• Falling inside home: Biomechanical restraints, stability during gait, and limits of stability should be assessed.
• Falling while shopping: Assess stability during gait, sensory orientation, and cognitive influences.
• Losing balance while doing laundry: Evaluate anticipatory postural adjustments, reactive postural responses, and biomechanical constraints.
• Falling while hanging laundry: Assess limits of stability, anticipatory postural adjustments, and sensory orientation.

Balance Assessment Tools

• For screening residents of a retirement community for fall risk, the appropriate tool is the TUG test.
• For a patient being discharged from rehab to a skilled nursing facility post-CVA, use the Berg Balance Scale.
• For assessing a patient's safety with ADLs at home, the Tinetti is suitable.
• For outpatients with a history of falls, use the FGA (Functional Gait Assessment).

Perturbation Strategies Assessment

• If a patient uses a hip or stepping strategy for small perturbations, assess ankle strength and ROM, somatosensation, and reactions/postural response.

Dual Tasking Balance

• Assess balance by having the patient perform TUG Cognitive (count backwards from a random number 20-100).
• Or, have the patient perform TUG Manual (carrying a glass of whatever).

Patient Questions for Unsteadiness and Falls

• Ask about falls in the past 6 months.
• Inquire whether the patient experiences dizziness or lightheadedness.
• Check for any feelings of weakness.
• Ask about changes in medication, sensation, vision, or hearing.
• Inquire about recent illnesses, incontinence, or surgeries.

Reactive Postural Responses

• PD (Parkinson's Disease): responses are present but lack amplitude, often using a stepping response.
• MS (Multiple Sclerosis): responses are large and exaggerated.
• Down Syndrome: responses are delayed.

CTSIB Foam with Eyes Closed

• Inability to complete the 30-second trial of standing on foam with eyes closed indicates an impaired vestibular system.

Berg Balance Scale Interpretation

• A score of 55/56 with complaints of instability requires exploring specific systems.
• Assess dynamic stability (FGA/cognitive TUG), fear of falling (ABC), reactive postural responses, and prioception and vestibular (CTSIB).

Anticipatory Postural Adjustments

• Impairments in anticipatory postural adjustments can cause problems with lifting objects, step initiation, pushing or pulling doors, and standing from a chair.

Seated Lateral Reach

• Falling during the seated lateral reach with eyes closed indicates impaired sensory orientation.
• Overshooting indicates reactive postural control issues.

DGI Score

• A DGI score of 6/24 indicates a high fall risk, as the cutoff score is <20/24.

BESTest Scores

• Reactive postural responses - difficulty with sudden/unexpected balance changes
• Sensory orientation - difficulty with activities requiring multiple sensory inputs
• Gait/cognitive processing - difficulty with cognitive multitasking

Discharge Recommendations

• Inpatient rehab: IRF-PAI should be used
• Home health: the OASIS

Early Mobility Algorithm

• Bed Mobility: rolling, supine to sit
• Sitting Balance: static, dynamic
• Standing Balance: static, dynamic
• Transfer: sit to stand, floor to stand
• Wheelchair: uses foot rests, uses brakes, propels straight, repositions, distance
• Ambulation: level of ambulation, different surfaces, stairs, distance
• Advanced Mobility

EDGE Task Force

• Evaluate and recommend outcome measures for specific disabilities based on reliability, validity, clinical utility, and applicability.

Ceiling Effect in Balance Measures

• FIM (Functional Independence Measure) used to have a ceiling effect for community-dwelling older adults, but it was replaced by IRF-PAI.

CPG Core Set of Outcome Measures

• Berg Balance Scale: Discriminates older adults that are at risk
  • 14 tasks, scored 1-4, 56 points max
• Risk stratification
  • 48+ = low fall risk
  • 40-47 = moderate fall risk
  • <40 = high fall risk
• Functional Gait Assessment: Assesses postural stability and ability to perform tasks while walking
  • 10 items, scored 0-3, 30 points max
  • 0 = severe impairment
  • 1 = moderate impairment
  • 2 = minimal impairment
  • 3 = normal ambulation
  • Cut-Off Score: <22 is predictive of falls
• Activity Specific Balance Scale
  • 16 items on an 11-point scale
  • 100 = complete confidence to complete task without LOB
  • <50 = low level of function/homebound
  • 50-80 = moderate level of function

  • 80 = high level of functioning

• 10 Meter Walk Test
  • Assesses gait speed over a short distance
  • <0.4 m/s: household ambulator
  • 0.4-0.8 m/s: limited community ambulator

  • 0.8 m/s: unlimited community ambulator

• 6 Minute Walk Test
  • Assesses gait endurance
  • <900 feet is predictive of frailty
• 5x Sit to Stand
  • Assesses lower body strength, dynamic balance, and functional mobility
  • Cut-Off Score: >14.2 seconds identifies balance dysfunction

Mobility Assessment

• The nurse must be consulted regarding the EVD (External Ventricular Drain) prior to mobility assessments.

Closely Watched Line

• An arterial line should be watched most closely during mobility.

Discharge Recommendations

• Based on AMPAC scores relating to assistance and home environment:
  • <18 = Inpatient/SNF
  • 18-20 = Home Health/SNF

  • 20 = Outpatient

Equipment Positioning for Mobility

• IV Line: above heart level
• Catheter: below bladder
• Oxygen: on rolling carrier to avoid kinks
• Telemetry: remains attached to the body
• Chest Tube: upright and below chest level
• NG/PEG: clamped
• Ventilator: must be very sensitive, use portable ventilator if possible
• EVD: level with the head, cannot mobilize unless clamped
• Arterial: must be very sensitive, clamp if possible

Electrotherapy Quiz Notes

• Asymmetrical biphasic: One pulse has two opposing currents of equal charge.
• Sensory TENS: Short pulse duration, high frequency, strong tingle.
• Maximum safe intensity for IFC: electrode area x 10 mA/cm².
• HVPC would healing: electrical potential is neutral, HVPC provides electrical potential.
• IFC: utilizes medium frequency (1,000-10,000).
• Motor Pain Control: 250 microsecond, 4 pps, 20 mA.
• Serotonergic = noxious stimulation
• Monopolar ratio is 1:4,Large = dispersive, Small = active

Ranges for TENS Pain Control

• Sensory: High frequency, low pulse duration, 80-100 pps, 40-80 microseconds.
• Motor: Low frequency, high pulse duration, 1-10 pps, 100-250 microseconds.
• Noxious: Lower frequency, higher pulse duration, 1-4 pps, 200-350 microseconds.
• Nerve Block: Very high frequency, very short pulse duration, >1000 pps, <10 microseconds.

Stability in Gait and Cognitive Processing

• PD (Parkinson's Disease): Freezing gait, festinating gait, cognitive deficits.
• CVA (Stroke): Aymmetrical ataxic gait, cognitive deficits.
• MS (Multiple Sclerosis): Ataxic gait, cognitive deficits.
• CP (Cerebral Palsy): Abnormal gait patterns - crouch, scissoring,.
• Down Syndrome: Slow gait speed, increased fall risk, cognitive and motor deficits.