Gait and balance disorder affect the mobility of the elderly and predispose them to falling, leading to various complications including immobility, pressure sores, fractures and other injuries. In this study, physical therapist-guided gait training demonstrated improvement in gait function and a decline in the number of falls. The mobility status, a reflection of gait and balance status was evaluated using the "Tinetti" scoring at initial evaluation and after 4-6 weeks. The Tinetti gait score was significantly greater among those who trained.
Falling is one of the leading causes of morbidity and mortality in the elderly (Baker, 1985; National Center of Health Statistics, 1986; Gryfe, Amies, & Ashley, 1977). It is also one of the leading causes of institutionalization for this age group (Tinetti, 1986). It has been shown that the use of the health care system is greater among fallers than non-fallers and fallers are more likely to decline in function (Kiel, 1991).
Numerous studies have been undertaken to identify risk factors for falls in the elderly (Tinetti, 1986; Robbins & Rubenstein,1989; Prudham & Evans, 1981; Sattin, 1992; Ryynanen, Kivela, & Honkanen et al., 1992; Tinetti, Liu, & Claus, 1993). Several classifications for the risk factors for falling have been proposed (Robbins & Rubenstein, 1989; Tinetti, Speechly, & Ginter, 1988). The main grouping of risk factors for which intervention can be applied are: (1) intrinsic factors which are inherent to the patient's state; (2) extrinsic factors which include environmental factors; and (3) the level of activity during the time of the fall (Tinetti & Speechley, 1989). Several prospective studies have consistently shown certain intrinsic risk factors that are significantly prevalent among fallers. The intrinsic risk factors most related to falls are: (1) impairment in musculoskeletal function "poor balance and poor muscular strength"; (2) cognitive impairment; (3) increased use of medications (Campbell, 1989; Nevitt, 1991; Tinetti, et al, 1988; Lord, 1991; Rubenstein & Robbins, 1990). While it is acknowledged that the cause of falling is multifactorial, Rubenstein and Robbins (1990) cited eight studies which showed gait and balance disorders to be the second most common cause of falls, second only to environmental factors. Gait and balance disorders are reflected in the maneuvers included in the Tinetti Mobility Testing (Tinetti, 1986). This mobility scoring has been found to be predictive of recurrent falls. Several studies indicate that these risk factors can be modifiable by exercise and therapy (Tinetti & Speechley, 1989).
Different approaches have been proposed in managing falls (Cwikel & Fried, 1992; Kilpack, et al., 1991); preventing falls or preventing injurious falls (Tinetti & Speechley, 1989). However, it has been shown that recurrent falls increase the chance of injury and disability and could indicate underlying conditions that increase the risk of death (Morse, et al., 1987; Lipsitz, et al-, 1991). A focused intervention, particularly rehabilitation which includes gait evaluation, gait training, and muscle strengthening, has been recommended as a preventive approach to reduce falls Tinetti, 1986). However, the actual impact of gait training in improving gait and balance and subsequently preventing the recurrence of falls has not been determined in a study.
The purpose of our study was to determine the effect of gait training in the occurrence of falling and in the improvement of gait and balance in elderly patients.
All patients 65 years and older with difficulty walking, who had an occurrence of at least one fall within 3 months were included in the study. All patients were seen in the outpatient clinic from January 1991 to December 1992. A chart review, comprehensive evaluation, brain CT scan. lumbar spine x-rays, laboratory data and all neurologic consultations were reviewed to establish the possible cause of gait disorder. All patients were counseled as to fall prevention and referred for gait training by a physical therapist in the same facility, 3 times a week for 4 weeks.
INSTRUMENT TO MEASURE MOBILITY: TINEHI SCALE
The mobility score which is the sum of gait and balance scores was tested using the "Tinetti scale" at initial evaluation and 4-6 weeks later (Appendix A). This scale is a simple measure of gait and balance status which provides a dynamic integrated assessment of mobility (Tinetti, 1986). The balance maneuvers include nine positions and position changes that stress stability. The gait assessments include rating the performance of eight activities in a serial fashion and will be judged using simple criteria. The better a subject's performance, the higher the score. Maximum score was 16 for balance and 12 for gait, the sum of which is the mobility score of 28.
A low Tinetti Mobility Score of 14 ±6 has been associated with recurrent fallers compared to a high score of 21 ±4 with one or no incidence of falls (p<0.0001) (Tinetti, 1986). In Tinetti's study, a gait score of less than 9 and a balance score of less than 10 have been found to be independent predictors for recurrent falling (p<.05 and p<.0001, respectively) Tinetti, 1986). This scale requires no equipment and can be learned quickly and easily by nurses, physicians, and other health care providers. Interrater reliability of 0.9 has been reported (Tinetti, 1986). This assessment can be completed in approximately 5 minutes or less.
Treatment: Gait and Balance Training Program
The goals of this program were to improve balance and coordination, to increase muscle strength of trunk and lower extremities, to ensure safe ambulation with or without assistive devices, and to teach skills and techniques of falls and recovery. This training includes various maneuvers that will: (1) help patients in a swing gait and in getting up from a seated position; (2) improve coordination and skill for point gaits; (3) strengthen the shoulders and elbow extensors which helps in maintaining balance; (4) help patients locate the proper center of gravity using a variety of gait exercises such as forward walking with eyes closed, backward walking with eyes open and closed and side stepping; and (5) assist patients for proper falling and recovery techniques. The basic therapy session was held at least 3 times per week for 1 hour.
To determine significant difference in changes in gait, balance scores and number of falls between the two groups: gait training and non-gait training, these scores were analyzed using one between (gait and non-gait training group) and one within (time) factor repeated measures analysis of variance (ANOVA). A Pearson r correlation was used to determine the correlation between number of falls and the Tinetti score. A p value <0.05 was considered statistically significant.
The clinical profile, including related disorders that may have caused gait disorder were noted (Table 1). Degenerative arthritis was the most common disease among these patients. A few had neurological disorders. Pain was not a major complaint and was described to be a mild to moderate level (average of 2 out of 5 pain scale) and was not different between the gait training and non-gait training group. The medications consisted of two prescription drugs and one over-the-counter drug per patient per day. None of these drugs were believed to contribute to gait and balance disorders in both groups.
Nineteen patients with a mean age of 76.5 ± 4.3 years received gait training for 4 weeks. Gait and balance scores improved and the number of falls decreased (Table 2). Eleven of the 30 patients elected not to participate in the formal gait training program; although not true controls, they form a comparison group to those who participated in the program. These 11 comparison patients with a mean age of 73.9 ±3.9 years also showed improvement in gait and balance scores but the frequency of falls did not change significantly. The change in the Tinetti Gait Score was significantly greater in the physical therapy versus the comparison group. Change in the Tinetti Balance and Mobility Scores was significantly greater in the physical therapy group. There was a significant difference in the number of falls between the two groups.
Cause of Gaff Disorder
Number of foils. Gaff and Balance Score Between the Gait Training and Non-gaff Training Groups
The most common intervention in elderly patients with gait and balance disorder with or without history of falling is gait retraining to improve mobility and thereby reduce recurrent falls. While rehabilitation has been recommended and found to be useful after acute events such as fractures and CVAs (Gibbon, 1993), its role in effectively minimizing risk for recurrent falling for elderly patients with chronic gait disability has not been objectively determined.
In the Tinetti study (1986), a low mobility scoring (sum of gait and balance scores) of <14±6 is associated with recurrent falling (Tinetti, 1986). In addition, a gait score of<9 and balance score of <10 are also independent predictors for recurrent falls. In this short-term study, the incidence of falling was low despite the high risk for recurrent falls as indicated by the patients' low gait and balance scores. The study further shows that the physical therapistguided gait training group demonstrated significant improvement in gait and balance function and a decline in the number of falls. Those who refused gait training showed significant improvement in the occurrence of falls despite some improvement in their gait and balance scores. It is important to note that for those who refused training, their score in spite of statistical improvement, remains to be clinically at risk as indicated by their mobility score. In addition, the Tinetti Mobility Score correlates with the number of falls. Further well-controlled study will be needed to establish the value of gait and balance training in reducing the recurrence of falls.
The result of this study clearly indicates that elderly patients with a history of falling and gait disorder can benefit from gait training. This has important nursing implications in preventing recurrence of falls. Assessment through comprehensive history and physical examination may provide a clue to the possible etiology of the patients falling and gait disorders. The nurse should be familiar with some of the more common causes of gait disorder in the elderly such as neurological disorders, degenerative arthritis, muscular abnormalities and certain medications (Prudham, 1981).
The Tinetti Scale (Tinetti, 1986) used in this study is simple, requires no equipment, and is quick and convenient to use to identify and quantify gait and balance disorder. The nursing staff can easily become familiar with the maneuvers. It takes about 5 minutes for the patient to perform the whole series of activities. The nurse should encourage the patient to perform these maneuvers bare-footed and unaided, if at all possible. If the patient needs an assistive device (e.g., a walker or cane) to be mobile, proper usage for safety should be assessed. This scale can be utilized at bedside in the hospital, in the clinic or at home during a nurse visit. The scale will provide important information as to the degree of severity and can be utilized to determine any improvement or deterioration of the gait and balance disorder. The information can then be communicated by the nurse to the other health care providers, to implement gait training, provide further medical evaluation, if needed, and advise closer supervision by family members for those patients at high risk for falling.
For intervention and subsequent evaluation, the goal of care for elderly patients with gait disorder is to maintain mobility rather than ambulation and to achieve maximum independence in performing activities of daily living (Rhymes, 1990). Once the patient's acute illness has stabilized and the medications are modified, physical therapy for gait and balance training can be initiated. Patients who are motivated and not demented are good candidates for physical therapy. The nurse needs to reinforce the training that the patient learns from the physical therapist and monitor gait and balance scores using the Tinetti Scale for improvement.
Physical therapy can also be conducted in a home setting. If the elderly patient needs walking aids to move around, the nurse needs to determine the patient's acceptance of such devices and determine how well they adjust to them. Although the patient will receive instruction from the physical therapist on the proper use of these assistive devices, the nurse should be able to assess if the elderly patient is able to comprehend and retain the instruction.
A community health nurse will be in a better position to identify potential problems that might be encountered in a home setting and instruct the patient and caregiver on the importance of making the home environment safe. This may involve installation of handrails and grab bars, if necessary. In some instances, this might require a change in the architectural design of the home to make it more accessible to the patient. Purchase of special equipment may be required to support mobility, such as the use of motorized chairs or lifts.
The nurse, along with the social worker, may tap community resources to help the patient obtain needed equipment. For patients who do not respond to conservative management, a surgical alternative should not be ruled out. In this case. the nurse can best serve the patient by assisting them in the decisionmaking process, by explaining advantages and possible complications of the procedure and reinforcing information given by other members of the interdisciplinary team.
For the elderly, safety and independence in activities of daily living are important in enhancing their quality of life. The nurse, as a member of the interdisciplinary team, plays an important role in assuring that this is maintained through careful assessment, planning, and intervention, as described above.
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Cause of Gaff Disorder
Number of foils. Gaff and Balance Score Between the Gait Training and Non-gaff Training Groups