I’m preparing my last inservice for the semester. Most of my inservices and research are directed toward rehab or outpatient clients, but I found an article on functional balance training for nursing home residents while searching for an article on balance. At ExPAAC a presenter (Barbara Resnick I believe) gave a talk in which she had a graph of how a person’s functional life goes when they go to assisted living or a nursing home – they start out at a certain level, have some sort of event (fall, hospitalization due to medical reasons, etc), they have rehab where we get them better but not to PLOF (for any number of reasons), they do fine for a bit, then another event, and the cycle continues.
(hope this shows up – my interpretation with time on x axis, function or QoL on y axis)
What if we could help reduce the number of bumps and the decline? This is what piqued my curiosity in this paper. Research in this population isn’t sexy – I can’t remember seeing an article about nursing home research in the media. It is a niche population currently, but as Boomers age I would expect it might come to the fore of our minds (first keep them out of nursing homes, then how to maximize independence in one; as a tangent, there is a great article about transitioning between levels of care entitled “But I am not moving”: residents perspectives on transitions within a continuing care retirement community, in The Gerontologist 2009; 49:418-427, by Tetyana Pylypiv Shippee).
Falls in nursing homes are a serious problem. The stats may be a bit old (I suspect there are more recent references they could use), but the CDC reports that 1/2 – 3/4 of nursing home residents fall a year (2x the rate in the community), with the average being 2.6 falls per person per year! Of those falls, 10-20% result in serious injuries, 2-6% result in fractures, but even worse is an increase in disability, functional decline, QoL, and fear of falling. Falls are multi-factorial (strength and balance and gait, environmental hazards, meds, etc), but PT’s can play a major part in addressing the problem.
The article I am presenting is “Rugelj D. The effect of functional balance training in frail nursing home residents. Arch Geron Ger. 2010; 50:192-197.” The author’s purpose was to “design and evaluate the set of exercises that would specifically target functional balance and would challenge most of the aspects of the balance performance: reaching borders of stability, balancing on compliant surface, stabilizing during head movements, and dual attention.”
The study participants were frail but independently mobile with no known neuro, cardo, or msk condition that would interfere with mobility. From 2 nursing homes (358 residents), 145 qualified and 59 agreed. 39 residents in the first home were randomly allocated to the experimental group (20) and the control (19), and in the second home all went to the experimental group. The author chose the following outcome measures: mCTSIB, Four-square step test (FSST), 10m walk test, the Berg, and the Barthel Index.
The training protocol was 5x/wk for 12 weeks, starting with 6 reps/ activity, increased to 10 in the 5th week and 15 in the 7th week. There were 14 activities at different stations which demanded balance, incorporating part of what would be in the residents’ daily routine in their functional tasks. Initially it took the participants 55 minutes, but by the end of the 12 weeks they were able to complete more reps in less time (45 minutes). The tasks were in 5 groups: rotation of head and body around vertical axis (4), shift of center of gravity to the border of stability (3), walking over obstacles or on a narrow line (3), relating to a soft supporting surface (3), and stair climbing.
The experimental group improved mCTSIB times on foam, improved times on FSST (>5 seconds), improved 10m walk test times (~3 seconds), and improved BBS by avg of 7 (54% >4, 36% >8), but had no change on the Barthel Index. The control group had no improvements, and between groups all outcome measures except the Barthel Index were significant.
The author concluded that targeted balance training using activities from a person’s daily life appear to be an effective way of improving balance function. There are several limitations to the paper: frailty was not defined; allocation between groups were convoluted and there was no intent to treat analysis (7 dropped out of the exercise group in the first two weeks, which caused the age to become significantly different between the two groups, so they excluded the oldest two to make it insignificant). Additionally the author uses a clinically significant change value of 4 for the Berg, however the paper cited is community-dwelling veterans. I have not encountered a clinically significant change score for nursing home populations (if someone knows what it is, please pass on the citation).
For me and my coworkers, we should obviously test to see where the patient’s deficits are and work on them, but then set up an appropriate and robust functional maintenance or restorative nursing program that incorporates this idea of multiple aspects of functional balance training. Any nursing home should look and see what they are doing for their residents – is it enough, or do you need to do more for the safety and quality of life of your residents? Further research is needed to determine the dose (reps and frequency), and which exercises should be done or areas addressed (are all 14 necessary?).