Case Report The Effects of a Pilates-Based Exercise Rehabilitation Program on Functional Outcome and Fall Risk Reduction in an Aging Adult Status-Post Traumatic Hip Fracture due to a Fall Adam Stivala, PT, DPT, GCS1; Greg Hartley, PT, DPT, GCS1,2

ABSTRACT Background: Currently, little information describing the relationship of Pilates-based strength and stability exercises with fall risk in the geriatric population exists. Purpose: The purpose of this report was to examine the impact of a Pilates-based rehabilitation (PBR) program on reducing fall risk in an aging adult status postfall with resulting hip fracture and open reduction and internal fixation. Case Description: The patient was an 84-year-old woman admitted to a skilled nursing facility (SNF) after a right hip fracture resulting from a fall at home. The patient’s relevant medical history included frequent falls due to loss of balance, a previous left hip fracture with resultant arthroplasty, and a stroke roughly 20 years prior. The patient received physical therapy and occupational therapy 6 days per week for 26 days in an SNF. The physical therapy intervention consisted of gait and transfer training, neuromuscular reeducation, and an adjunct of specialized PBR exercises for the following impairments: decreased core strength and awareness and poor dynamic stabilization during functional activities. Outcomes: The patient demonstrated increases in lower extremity strength and active range of motion, ambulation distance and speed, and transfer ability. The patient was able to return home and live with her husband while requiring only incidental assistance with activities of daily living. She was able to independently ambulate around her home with her rolling walker. Her fall risk was also reduced from initial evaluation based on several fall risk assessments, including the Four Square Step Test, the Berg Balance Scale, and the Timed Up and Go. Conclusion: This case illustrates the benefit of integrating PBR exercises into a standard SNF rehabilitation program, which may contribute to decreased fall risk. 1Rehabilitation Department, St Catherine’s Rehabilitation Hospital, North Miami, Florida. 2University of Miami, Coral Gables, Florida. The authors have no conflicts of interest to declare. Address correspondence to: Greg Hartley, PT, DPT, GCS, Rehabilitation Department, St Catherine’s Rehabilitation Hospital, 1050 NE 125th St, North Miami, FL 33161 ([email protected]). Decision editor: Richard Bohannon DOI: 10.1519/JPT.0b013e3182abe7a9

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Key Words: fall risk, geriatrics, hip fracture, physical therapy, Pilates (J Geriatr Phys Ther 2014;37:136–145.)

INTRODUCTION Falls are a major public health concern for the older adults, and their repercussions can create significant challenges across all spectrums of patient care. Falls in aging adults can result in institutionalization, additional injury, and death.1 All too often, an older patient may attest independence with ambulation and mobility premorbidly, yet may have been frail and at an elevated fall risk for months or years. During the rehabilitation course of an aging adult status postfall, rehabilitation should focus on future fall prevention.2 This can be accomplished in various ways with essential components, including improving dynamic standing balance, strengthening the lower extremity and trunk musculature, and modifying the home environment to eliminate unnecessary hazards. An often overlooked aspect of fall prevention, sometimes impacted secondarily as a result of functional training, is core strength and stability, which according to Willson et al3 is the ability of the lumbopelvic hip complex to prevent buckling and to return to equilibrium after perturbation. The Pilates method (PM) or “Contrology,” developed by Joseph Pilates in the 1940s for strengthening the mind and body, uses several fundamental principles to achieve well-being and total body conditioning.4 The original fundamental principles proposed by Pilates are whole body movement, breathing, balanced muscle development, concentration, control, centering, precision, and rhythm; a complete description of these principles is beyond the scope of this article.5 Over the last few decades, Pilates’ original work has been refined and elaborated upon; PM has emerged as a popular form of strength and conditioning for people of all ages, yet has been used primarily as a modality Volume 37 • Number 3 • July-September 2014

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for those desiring toning and conditioning or as an adjunct to traditional rehabilitation. It is important to note, however, that exercise and rehabilitation professionals today use an adapted form of the traditional PM, referred to as Pilates-based exercises,6 and for the purposes of this article will be referred to as Pilates-based rehabilitation (PBR). The rationale for this adaptation is many traditional PM exercises are difficult for even advanced practitioners of PM and would be nearly impossible to administer in a rehabilitation setting based on this difficulty level and the risk of injury to the patient. Also, specific equipment for PM may not be available in every hospital or rehabilitation setting, so PBR exercises allow a wide range of health care professionals to benefit from the PM movement theory. In contemporary PM, the principle of core strength and stability contributes significantly to proper spinal alignment, enhanced breathing biomechanics, and above all, greater balance and coordination of the extremities.7Core stability can be defined as the ability to stabilize the spine as a result of muscle activity, and core strength is the ability of that musculature to produce force through contractile pressure and intraabdominal pressure.8 Presently, no research has examined the relationship, if any, between core strength and stability developed using a PBR program with a lower incidence of falls as measured by clinical functional assessments. Current research on PBR is inconclusive, yet some studies have established a relationship between PBR and improvement in function. Johnson et al9 demonstrated that a PBR program improved dynamic balance in healthy adults as measured by the Functional Reach Test (FRT). Bird et al10 compared a group of older, community-dwelling adults who participated in a 5-week PBR intervention with a control group receiving no intervention. Although there were no statistically significant changes found, the authors did note that subjects receiving the PBR intervention demonstrated improved static and dynamic balance.10 Muscular strength and activation can be directly linked to balance impairments. For example, specific abdominal muscle strength and activation can be related to core and spinal stability. Hodges and Richardson11 were able to demonstrate that during rapid upper extremity movements, the transversus abdominus (TA) was the first muscle active in healthy subjects without low back pain and that TA activation was delayed in subjects with low back pain. These findings suggest that, in healthy individuals, core stability is subconsciously engaged to support the extremities in balanced movement patterns. The TA has been demonstrated as a primary stabilizer of the spine and plays an important part in core stabilization.11 In a systematic literature review including articles comparing lower extremity and trunk fatigue to effects on balance and functional tasks in older adults, Helbostad et al12 concluded that fatigue of the lower extremity and trunk muscles impairs balance and performance of functional tasks. Journal of GERIATRIC Physical Therapy

Concurrently, balance training has proven effective in improving functional and static balance while decreasing falling frequency in older women with osteoporosis.13 Numerous research studies have demonstrated that altered balance is the greatest contributor toward falls in the older adults, with fall incidence and balance deficits highly correlated.14-16 From the lack of evidence relating PBR exercises and core strength/stability to fall risk, more research needs to be performed to examine this relationship. This case report will describe the impact of a PBR program as a primary intervention and provide information about the direct effects of this intervention in a patient with severe functional limitations and balance impairments. The purpose of this case report was to examine the immediate effects of a PBR exercise program on functional outcome measures related to fall risk in a patient with a right hip fracture due to a fall.

CASE DESCRIPTION Patient History The patient was a woman aged 84 years who was admitted to the emergency department after sustaining a fall at home. She reported that she was independent at home with basic activities of daily living (ADL) and functional mobility, including household ambulation using a rolling walker (RW) before this incident. The patient had previously been treated in an inpatient rehabilitation hospital following her stroke in 1987, and her home environment had been modified to reduce fall risk and facilitate independent mobility. A home evaluation was not deemed necessary by the physical or occupational therapists, because the patient had sufficient home modification from previous rehabilitation episodes. The patient stated that she had grab bars in her bathroom and shower, a shower bench, no throw rugs, and good lighting throughout the home. Despite being independent in her home, the patient reported having more than 3 falls in the past year. She and her husband relied on the services of her part-time caregiver/homemaker 4 to 6 hours daily for shopping and other instrumental ADL. The patient recalled that she lost her balance in the kitchen, fell into the refrigerator while reaching for an item, and had immediate pain in her right hip. Two days following her fall, an open reduction and internal fixation was performed on her right femur. Her medical history included a stroke in 1987 with resulting left hemiparesis, atrial fibrillation, a left hip arthroplasty in 2010 because of a fall at home, coronary artery disease with stent placement, osteoporosis, frequent falls, and chronic lower extremity wounds due to venous insufficiency. Since her left hip fracture in 2010, she had been independent with ambulation and ADL at home using a RW and was no longer on hip precautions from that surgery. The patient was living with her husband (5 years older than her), who was her primary caregiver, in a single-story home with one step to enter. 137

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The patient was weight bearing as tolerated postsurgery on the recently fractured right extremity. On the basis of her history of frequent falls, multiple confounding comorbidities affecting functional mobility and quality of life, and her motivation to recover and return home, the patient was deemed a good candidate for the PBR program. Although she maintained that she was physically active before her accident, the patient admitted that she performed no formal exercise before her recent fall and was unfamiliar with PBR or PM.

Examination and Evaluation An evaluation was performed on the patient’s first day of admission to the skilled nursing facility (SNF). The patient was previously admitted to a rehabilitation hospital but could not tolerate the intensity of therapy in that setting and was discharged to an SNF. The patient’s pain was rated, using the 0 to 10 Numeric Pain Rating Scale (NPRS), as 5 to 6 of 10 constantly in the right hip, radiating down her right lower limb, worsened with passive/active range of motion and with weight bearing during transfers and gait. The patient demonstrated an antalgic gait pattern with decreased weight bearing on the right lower extremity because of increased pain of 6 of 10 from her resting pain level of 5 of 10. The patient was alert and oriented to time, person, and place. The patient had numerous chronic lower extremity wounds, with distal extremities affected greater than proximal. Her bilateral lower extremity sensation was impaired to light touch, and gross lower extremity movement patterns were bradykinetic because of pain and impaired volitional movement on the hemiparetic side (left); volitional movement on her left lower extremity was 70% to 80% of normal range at the ankle, knee, and hip for flexion and extension. The patient appeared extremely frail, and postural assessment revealed severe thoracic kyphosis, forward head posture, marked muscular atrophy in the left arm and leg, and decreased weight bearing on the right extremity during functional activities. Because the patient was unable to walk more than a few steps on initial evaluation, gait and transfer training were implemented in the parallel bars and with a RW until the patient was able to ambulate at least 50 ft (15.24 m) with a RW and performing greater than 75% of the activity without physical assistance. Standardized functional assessments were administered as appropriate when the patient was judged adequately functional and safe to complete the assessments (see Table 1). These included the Activitiesspecific Balance Confidence (ABC) scale, Timed Up and Go (TUG), FRT, timed 10-Meter Walk Test (10MWT), and the Four Square Step Test (FSST). Functional Independence Measure scoring methodology was used for transfers, gait, and bed mobility. At the time of SNF admission, the patient was rated at performing less than 25% of the task for bed mobility, transfers, and gait (total assistance). 138

A reproducible measurement of core strength was proposed as an adjunct to the functional assessments in evaluation of the effectiveness of the PBR exercises on fall risk reduction. Since core strength is a complex phenomenon of muscular integration, breathing, and alignment, the patient’s core strength was measured using a timed PBR exercise called supine 90/90. A movement familiar to all practitioners of PM and PBR, this exercise functions as a modified manual muscle test for the core musculature (transverses abdominus, internal/external abdominal oblique, and rectus abdominus). It was measured as a timed isometric contraction (sustained to fatigue) for ease of use and reproducibility. The timer was stopped when form deviated from the correct position. In this exercise, the patient lies in supine position and attempts to bring the knees and hips to 90⬚ angles and maintain the position for as long as possible (Figure 1). The patient was instructed to keep the lumbar spine and pelvis in contact with the mat for the duration of the assessment. This assessment was used because of limited functional assessments of core strength in current literature for the severely debilitated geriatric population. Because the patient was unable to achieve many positions required to measure core strength such as the flexor endurance test and side bridge test proposed by McGill et al,17 the supine 90/90 timed isometric measurement was used because of efficiency and ease of administration. It should be noted that although core strength is an important component of PBR and functional tasks, fall risk reduction assessments are the primary outcome measures in this case study. The TUG is an objective, valid, and reliable test based on research literature and measures the time, in seconds, a person takes to stand up from a standard armchair, walk 3 m, turn 180⬚, walk back to the chair, and sit down. The patient was given a practice trial followed by 2 timed trials, which were then averaged.18-20 The patient was wearing hospital socks with grip and using a RW for pre- and postintervention testing. A lower TUG score indicates a lower fall risk, with scores of greater than 30 seconds corresponding with functional dependence in people with pathology.20 Adults aged 65 years or older who took 13.5 seconds or longer to perform the TUG were classified as fallers, with an overall correct prediction rate of 90%.21 The ABC is a questionnaire designed to measure the aspect of psychological impact of balance impairment and/ or falls. The ABC has been demonstrated to be reliable and valid, on the basis of research in community-dwelling elders by Powell and Myers.22 The ABC was administered verbally to the patient before and after the intervention. Scores range from 0% to 100%. A score of 80% is indicative of a high level of physical functioning, 50% to 80% indicative of a moderate level of physical functioning, and less than 50% indicative of a low level of physical functioning.22 Volume 37 • Number 3 • July-September 2014

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Table 1. Functional Assessments and Outcome Measures Outcome Measure

Discharge (Day 26, Which Included 19 Days of Pilates-Based Rehabilitation Intervention)

Baseline (Admission: Day 1)

Timed Up and Go17,18

76.7 seconds with a RW (high fall risk)

40.5 seconds with a RW (high fall risk) (⬎30 predictive of requiring assistive device for ambulation and being dependent in ADL for frail older adults)20

Activities-specific Balance Confidence scale21

42.5% (⬍50% ⫽ low level of physical functioning)

63.75% (50%-80% ⫽ moderate level of physical functioning)

Four Square Step Test22,23

132 seconds with a RW and minimal assistance

102.5 seconds with a RW, independently (⬎15 seconds ⫽ at risk for multiple falls) 23

Timed 10-Meter Walk Test (fast velocity)24-27

47.1 seconds with a RW (0.21 m/s)

22.2 seconds with a RW (0.45 m/s) (normal is 0.8 to 1.2 m/s for healthy women aged 80-89 y)24

Functional Reach28,29

4 in (10.16 cm)

8 in (20.32 cm) [⬍7 in ⫽ subjects were more likely to fall]29

Numeric Pain Rating Scale30

5-6/10, right hip and thigh

No complaint of pain

Passive range of motion (goniometry)

Left lower extremity—within functional limits

Bilateral lower extremities were grossly within functional limits

Right lower extremity—hip flexion 100⬚, otherwise within functional limits Manual muscle testing (gross)

Bilateral hips: 2⫺/5

Bilateral hips: 3⫹/5

Bilateral knees: 2⫹/5

Bilateral knees: 3⫹/5

Bilateral ankles: 2⫹/5

Bilateral ankles: 3⫹/5

Supine 90/90 isometric

⬍1 second

7.6 seconds

Bed mobilitya

Total assistance at day 1, minimal assistance at day 8

Independent

Ambulationa

Total assistance with a RW for 2 ft (0.61 m) indoors on tile at day 1; minimal assistance with a RW at day 8

Independent with a RW for 500 ft (152.4 m) indoors and outdoors on varying surfaces, including gravel and pavement

Transfersa

Total assistance with a RW at day 1, minimal assistance with a RW at day 8

Independent with a RW

Abbreviations: ADL, activities of daily living; RW, rolling walker. aFunctional Independence Measure (FIM) Scoring.

The FSST is a timed test, designed to assess the rapid change in direction while stepping forward, backward, and sideways over a low obstacle with or without an assistive device.23 The reliability and validity of the FSST has been documented in a group of community-dwelling adults aged 65 years and older.24 A lower score indicates a lower fall risk and higher functional mobility with gait and negotiating obstacles, with scores of greater than 15 seconds indicative of the subject being at risk for multiple falls.24 The 10MWT is a functional assessment measuring walking speed. The 10MWT has been demonstrated to be reliable and valid across various disease processes, as a measure of gait speed.25-27 Gait speed variability has been correlated to increased fall risk in older adults.28 The patient performed the 10MWT with the instructions to walk as fast as possible for 3 bouts, using a RW and wearing hospital socks with grip. The test was administered pre- and postintervention, and the recorded measurements for each assessment were averaged. A lower score indicates a decreased fall risk and higher gait speed, with the average Journal of GERIATRIC Physical Therapy

fast walking speed for healthy women aged 80 to 89 years at 1.2 m/s.25,26 The FRT is a clinical measure designed as a quick screen for balance problems in older adults. The FRT has shown to be reliable and valid against other measures of balance and fall risk, including walking speed, single-leg stance, and mobility skills.29,30 The patient was assessed with a RW within reach but not using the RW for support during the assessment. A higher score indicates a decreased fall risk and improved dynamic standing balance, with scores of less than 7 in indicative of subjects being at more risk of fall.29 The FRT assessment was very similar to the mechanism of injury the patient sustained resulting in her hip fracture, and was judged by the authors to be an adequate predictor of the patient’s functional gains and future fall risk. The 0 to 10 NPRS is used in the clinic on the basis of validity, reliability, and ease of use for the clinician and patient.31 The patient was verbally asked the intensity of her pain after each treatment session on a scale from 0 to 10, with 0 representing “no pain” and 10 representing “worst possible pain.” 139

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Figure 1. Patient demonstrating supine 90/90 isometric exercise at final day rehabilitation before discharge home; a wedge was used under the upper trunk for comfort and to decrease the stress on the lumbar spine.

as a licensed physical therapist and 2-year experience as a certified Polestar PM rehabilitation instructor. The physical therapy program was based on basic PBR principles of breathing, core strengthening and stabilization, postural awareness, and dynamic stabilization exercises, which progressed from an assisted supine program to a dynamic standing program.4,5 Gait training, transfers, and bed mobility were also incorporated into the treatment sessions using PBR concepts and components with specific verbal and manual cues for core activation and awareness similar to the techniques learned with the exercises. The PBR program was divided into 3 phases on the basis of PM principles and consisted of breathing/core strength and stability, weight bearing and alignment of the extremities, and movement integration. Because true muscle strength gains may take up to 6 weeks in healthy adults, the emphasis of the rehabilitation program was on active engagement of muscles and improved postural and muscular awareness to achieve desired functional outcomes.33

INTERVENTION Breathing/Core Strength and Stability The PBR program was implemented on day 8 of the patient’s rehabilitation, when the patient used minimal assistance with transfers, bed mobility, and ambulation to 50 ft with a RW. The goal of the PBR program was to use at least 5 to 6 days on each of the 3 phases while incorporating each phase’s exercises as tolerated by the patient. After consenting and agreeing to participate in this case report, the patient was educated about the PBR and the requirements of the rehabilitation process. Each physical therapy treatment session consisted of various structured and progressive PBR exercises designed to promote increased postural and core awareness with dynamic stabilization of the trunk and extremities by improving core strength and stability. Postural and core awareness can be described as conscious, volitional activation of the abdominal musculature to promote optimal alignment of the spine and pelvis to maintain the patient’s center of gravity over her base of support. Dynamic stabilization is a component of postural and core awareness that requires neuromuscular power and control through the trunk and lower extremities to increase dynamic balance.32 The patient also received occupational therapy that was consistent with the patient’s physical therapy discharge goals yet unrelated to the specific PBR interventions. The patient received 1 hour per day of physical therapy with PBR consisting of supine, sitting, and standing activities that also involved a therapy ball (medium size 95 cm or 37.4 in), resistive banding, and free weights. The physical therapy examination, evaluation, interventions, and discharge assessment were performed and administered by a geriatric physical therapy resident in an American Physical Therapy Association–credentialed postprofessional geriatric residency program. The resident had 9-month experience 140

The patient was instructed in the PBR principles of breathing and core strength and stability, using several supine mat exercises.4,5 The focus of this phase was to use breathing to facilitate movement and to learn the proper engagement of the abdominal and spinal muscles to create core stability and strength and, therefore, improve functional balance.12 All exercises were performed in supine position with adequate head support and active assistance when required. This phase was implemented on the patient’s eighth day of rehabilitation, with functional transfer and gait training, and was the predominate exercise modality from day 8 to day 13 of rehabilitation. Active assistance was provided by the therapist, but the patient was able to perform the exercises adequately after the first instructional session. These exercises were performed in the same position, supine on a mat table with bent knees and feet on the mat, so there is a balance of safety as well as improving range of motion and muscle contraction as tolerated by the patient. Recommended frequency for the patient was one set of the exercises until fatigue, and generally 6 to 15 repetitions depending on the patient’s familiarity and the difficulty of the exercises. With all exercises, the patient was encouraged to exhale on exertion, completing either 1 or 2 breath cycles based on the movement pattern. Before beginning the selected exercises, the patient was instructed in engaging the TA through imagery, manual, and verbal cues. Refer to Table 2 for a complete description of the breathing/core strength and stability intervention.

Weight Bearing and Alignment of the Extremities The focus with the next phase of PBR was to promote proper weight bearing and alignment of the extremities Volume 37 • Number 3 • July-September 2014

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Table 2. Breathing and Core Strength and Stability Interventionsa Exercise/Movement Pattern

Description

Frequency, Duration

Pelvic tilts/pelvic clock

With bent knees and feet on mat, anterior/posterior tilting of the pelvis with static hold and breath control, pelvic neutral positioning

2 sets of 10 in each direction with isometric hold at end range for 3 seconds

Basic bridging with spine articulation

With bent knees and feet on mat, lifting of the pelvis to neutral while articulating spinal segments with breath control

3 sets of 10 with isometric hold at top of bridge for 3 seconds. Two complete breaths are performed on each repetition. Manual resistance may be applied

Bent knee fallout

With bent knees and feet on mat, abdominals engage to control pelvis while unilateral knee abducts to end range and returns to starting point

3 sets of 10 repetitions with each knee, isometric hold at starting and ending position for 3 seconds. Manual resistance may be applied

Supine 90/90 (tabletop position)

With bent knees and feet on mat, patient lifts unilateral leg to 90⬚ at hip and knee, and follows with opposite leg

2 sets of 10 with bilateral lower extremities. Alternatively, patient can hold isometrically in top position with breathing focus

Knee rocking

With bent knees and feet on mat, patient adducts ball or pillow between knees and drops both knees to one side

3 sets of 10 repetitions to each side. Head turning to contralateral side can increase spine stretch. Manual resistance may be applied

Femur arcs

Starting in supine 90/90, unilateral leg moves at hip only to touch heel down to mat, returns to start position

2 sets of 10 with bilateral lower extremities

aThese basic exercises were designed to familiarize the patient with the movement patterns and serve to assist with functional transfers. The patient was able to complete the group of exercises in one physical therapy treatment session.

while emphasizing core stability and correct postural alignment to improve balance with transfers, ambulation, and ADL.13-16 A full-length mirror was used for visual feedback of posture with verbal and tactile cues from the physical therapist for normal spinal alignment. The PBR exercises specifically assisted the patient with learning to activate the correct synergistic muscle patterns in the core to facilitate improved and normalized spinal alignment. This phase was gradually incorporated with phase 1 on day 14 to day 19, once the patient was able to perform all sets and repetitions recommended in phase 1 without assistance or prompting by the therapist. This second phase was extremely important for this patient because of her antalgic gait pattern with decreased weight bearing on the right leg and impaired volitional movement on her left leg from chronic hemiparesis and maladapted movement patterns. A therapy ball (medium/large sized, 95 cm/37.4 in diameter) was used in the parallel bars for some of these exercises, and a mirror was used for visual feedback with posture and alignment. Refer to Table 3 for a complete description of the weight bearing and alignment of the extremities interventions.

patterns learned through the first phase of mat exercises with core strength and activation. This phase was incorporated with phase 2 from day 20 until her discharge on the 26th day of her rehabilitation, when the patient was able to perform phase 2 exercise without assistance or prompting by the therapist. These exercises incorporate rotational and multiplanar movements into functional activities rather than use uniplanar muscle strengthening techniques. In the same vein as proprioceptive neuromuscular facilitation, these exercises are designed to elicit greater neuromuscular recruitment and activation to achieve greater balance and strength. In addition, PBR focuses on total body integration to achieve functional goals, such as transfers, gait, and activities of daily living. With the addition of specific, guided core stability exercises, PBR can help patients reduce fall risk by activating the primary mechanism in the body used to prevent loss of balance.3 At discharge, the patient was provided with a home exercise program based on her PBR mat exercises to perform 3 to 4 days per week in conjunction with home health physical therapist.

Movement Integration

OUTCOMES

The final phase of the PBR program, movement integration, unites all the principles of the PBR to facilitate deliberate, synergistic movement patterns in multiplanar or multijoint relationships to prevent falls by improving balance.13-16 This phase was most closely related to reducing fall risk for the patient on the basis of her history and discharge plans to return home. Refer to Table 4 for a complete description of the movement integration exercises. The PBR exercises are designed to use the synergistic and deliberate movement

After a 26-day SNF stay (which included 19 days of PBR intervention), the patient was discharged home with her husband and a part-time caregiver/homemaker (4-6 hours per day) at a modified independent level (needing an assistive device or additional time but no human assistance) with bed mobility, transfers, and ambulation up to 500 ft (152.4 m) with a RW. The patient made improvements in gait speed, TUG score, ABC scale, FSST,

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Table 3. Weight Bearing and Alignment of the Extremities Interventionsa Exercise/Movement Pattern

Description

Frequency, Duration

Seated therapy ball—anterior/posterior rocking

With hips centered on a therapy ball (medium/ large size) and feet on floor, the patient shifts weight anterior to toes and posterior to heels, maintaining erect spine

2 sets of 10 moving anterior and posterior with 3-second hold on each extreme. Verbal cues for posture and weight bearing provided as necessary

Seated therapy ball—marching in neutral, marching with abduction

With hips centered on a medium-/large-sized therapy ball and feet on floor, unilateral lower extremity lifts 2 to 3 in from floor with hip and knee flexion

2 sets of 10 for bilateral lower extremity, isometric hold with hip flexion if possible, verbal cues for posture and weight bearing

Seated therapy ball—bouncing

With hips centered on a medium-/large-sized therapy ball and feet on floor, use ball to generate small oscillations vertically without losing contact

3 sets of 20 repetitions, using upper extremities for stability if needed. Verbal cues for posture and to increase oscillation height as tolerated

Seated therapy ball—unilateral straight leg extension

With hips centered on a medium-/large-sized therapy ball and feet on floor, unilateral lower extremity extends straight to touch heel to floor

3 sets of 10 repetitions. Ankle flexion/extension may be added to increas difficulty

Standing therapy ball—anterior/posterior leaning (modified inclined plank)

With medium-/large-sized therapy ball on mat at chest height and hands on ball, patient leans body weight anterior onto hands with shoulder extension and leans posterior onto heels with shoulder flexion

3 sets of 10, with verbal cues to increase leaning distance as tolerated, static hold of 3 seconds at apex of anterior lean if possible, 2 complete breaths with exercise

aThis is a fundamental progression that could be incorporated into any patient routine. The patient was able to complete all sets and repetitions for one group based on her progression with the exercises in one physical therapy treatment session.

strength (supine 90/90 test), passive range of motion and reducing pain compared with initial measurement (Table 1; Figure 1). On the basis of the functional assessments performed postintervention, the patient was still at a high risk for falls even though her scores on the functional assessments were lower than her preintervention assessment. The patient’s initial TUG score, 76.7 seconds, with a RW (high fall risk), decreased by almost one-half to 40.5 seconds with a RW (high fall risk) for an improvement of 36.2 seconds. The patient’s ABC score improved from 42.5%, which indicates low physical functioning,

to 63.75%, which represents a moderate level of physical functioning.22 With the FSST, the patient improved her score by 30.5 seconds from 132.5 to 102 seconds, which still places the patient at a significant risk for falls. On the basis of the 10MWT, the patient’s average gait speed improved by 0.24 m/s, from 0.21 to 0.45 m/s, which is still less than her age-adjusted normal gait speed of 1.2 m/s for healthy women aged 80 to 89 years.26,27 Her FRT score improved by 50% from 4 in the metric values are excessively precise. Round to the tenths place (ie, 10.2, 20.3, 17.8) are indicative of a decreased fall risk. The patient’s timed isometric supine 90/90 improved from less than

Table 4. Movement Integration Interventionsa Exercise/Movement Pattern

Description

Frequency, Duration

Quadruped—hip and shoulder flexion/ extension (modified child’s pose)

With knees bent and weight equally distributed on hands and knees, the patient shifts weight anterior and posterior, maintaining spinal alignment

2 sets of 10 anterior and posterior. Verbal cues for spine alignment and breathing with flexion and extension. Older patients may not tolerate this position for a long duration

Standing single leg stance with unilateral lower extremity circumduction

Standing with pelvis and spine in neutral, patient stand on single leg while performing circumduction with opposite leg

2 sets of 10 in each direction, alternating sides between sets. Verbal cues for articulation of lower extremity with movement and control

Sit to stand from chair holding therapy ball with trunk flexion/extension

Holding medium-/large-sized therapy ball, patient stands from chair, reaching ball overhead in gross extension, and returning to sitting

2 sets of 5 emphasizing breathing to facilitate movement, breathing to hinder movement as tolerated to progress

Standing trunk rotation with therapy ball

With knees and hips slightly flexed and holding a medium-/large-sized therapy ball, rotate to bilateral sides to end range of motion

2 sets of 10 bilaterally, emphasis on breathing to facilitate movement with eyes following ball

aAs

stated in Table 3, this is a more advanced progression that could be incorporated into a patient routine. The patient was able to complete all sets and repetitions for one group based on her progression with the exercises during one physical therapy treatment session.

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1 second sustained hold to 7.6 seconds. Using the NPRS, her pain improved from 5 to 6 of 10 to 0 of 10 at discharge, allowing her to ambulate and perform ADL pain free. The minimal clinically important difference (MCID) for the NPRS in hospital/emergency department population is 1.3 points for the patient with acute pain.34

DISCUSSION This case report explored the impact of inpatient rehabilitation including a PBR program on functional mobility and fall risk in a medically complex aging adult with a history of falls. The findings of this report demonstrate that a rehabilitation program in an SNF setting that incorporates PBR exercises into a standard rehabilitation program may decrease fall risk and reduce pain in patients with multiple comorbidities recovering from hip fracture. A number of contributing factors that may have limited additional gains in mobility or improvements in functional measures exist. Before her fall, the patient did not actively engage in an exercise program at home and was relatively sedentary. Also, the patient was receiving occupational therapy, which may have contributed to her improvement during the course of her rehabilitation. Despite improvements with respect to all functional assessments and outcome measures, the patient was still a high risk for future falls at the time of discharge from the SNF on the basis of her TUG score, gait speed, ABC, and FSST.16-28 The patient’s lower extremity muscle strength improved generally by one grade. At discharge, her lower extremity strength was grossly 3 of 5 level, allowing for functional activities. Limitations in further strength gains could be attributed to residual effects of her stroke, severe sarcopenia, malnourishment, dehydration, or medication adverse effects. Also, Guccione et al33 have noted that a minimum of 6 weeks is needed to achieve a true strengthening response in muscle tissue. Functional skills such as bed mobility, which includes rolling, scooting, and transferring from supine to sitting, were improved when verbal instructions were given to the patient to integrate the PBR exercises into the activity, such as in part-task training, which is a method of breaking down complex movements patterns into simpler ones that the patient can more readily achieve. The patient demonstrated meaningful clinical improvements across all functional assessments and measurements; yet the patient’s performance still indicates a high fall risk across all assessments based on normative values and her history of multiple falls. However, the patient did achieve minimally important gains on most of the functional assessments performed, which, on the basis of her progress in therapy, may improve additionally as the patient continues rehabilitation in her home and outpatient settings. Journal of GERIATRIC Physical Therapy

The patient’s TUG score still placed her at a high risk for falls and strongly correlates with functional dependence in people with pathology.19,20 The MCID for the TUG is a change of 7.7 seconds with a moderate effect size, which the patient accomplished, possibly because of her low functional level at evaluation.35 The minimal detectable change or the minimal change not due to error, for the ABC using a 95% confidence interval is 13%.36 The patient had an improvement on the ABC of 21.2%. The patient reported that she felt more confident to perform many items on the ABC after the intervention not only because of her improved mobility but also because she could rely on her husband or part-time caregiver for support. Although MCID and minimal detectable change have not been established for the FSST, a cutoff score of greater than 12 seconds was associated with a sensitivity of 80% and specificity of 92% for identifying subjects at risk for falls with 1 or more risk factors.37 The FSST was selected for its uniqueness of simulating a nonclinical environment with negotiation of obstacles, and proved to be the most challenging functional test with the smallest improvement score. The patient demonstrated a substantial meaningful change in gait speed of 0.24 m/s, greater than the 0.10 m/s described in the literature as the MCID.38 On the basis of previous level of function, the patient used a RW before her injury and planned on continuing to use the RW well before discharge from SNF; this may have provided her some security with ambulation and substantial increases in gait speed in the clinical setting. The minimal detectable change for the FRT is 1.45 in (3.7 cm) based on patients with acute stroke, which is pathology comparable to the patient’s level of injury and functioning.39 The patient gained 4 in (10.2 cm) and was considered the functional assessment that most replicated the patient’s mechanism of injury. This was an important functional assessment, which demonstrated a decreased fall risk and an improvement of patient confidence in ADL, which can predispose to falls. Being pain-free was the primary goal of the patient, as she reported that it had been a significant barrier to her functional mobility with previous therapy in the rehabilitation hospital. Pain reduced significantly to the point of no pain at the time of discharge. As previously stated, the patient achieved greater than the MCID for the NPRS. The patient’s timed isometric supine 90/90 improved from less than 1 to 7.6 seconds. This may reflect an increase in abdominal muscle strength, greater core strength, and also improved core and postural awareness. Although the supine 90/90 is not a validated clinical assessment, it did help bolster patient morale and gave the examiner a better idea of the patient’s functionality and attention to task. As this was not a primary focus of this case study but an 143

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important component, further investigation is needed to determine the relationship, if any, of core strength with fall risk. Finally, the most apparent clinical improvement was the decrease in the amount of assistance required for gait, transfers, and bed mobility, which improved from total dependence with a RW on admission to modified independent with a RW at discharge, including a gross ambulatory distance improvement of 498 ft (151.79 m), from 2 ft (0.61 m) to 500 ft (152.4 m), with a RW. Mobility improvements were the most important to the patient even though she relied on her husband and caregiver for support with ADL and mobility at times. Core strength and stability were important components of this case study and, unfortunately, are difficult to quantify and assess on the basis of morphological differences, interaction of several muscle synergies, and lack of standardized assessments specific to these concepts for the geriatric patient. The patient improved in her ability to perform a movement pattern (supine 90/90), which may be interpreted as improved core strength and stability. Although not measured explicitly, postural awareness refers to the kinesthetic ability to sense the body’s alignment and position in relation to gravity, center of mass, and base of support.40 Postural awareness is an important component of balance, and therefore, fall risk but was not the primary focus of this study. Through tactile, verbal, and visual cues, the patient was encouraged to incorporate the PBR exercises to improve postural awareness, which may have improved static and dynamic balance with sitting, standing, and gait. Future research should investigate the relationship between PBR exercises and fall risk reduction, and also core strength/stability and fall risk in the geriatric population, using larger sample populations and additional variables. Specifically, randomized controlled trials should be explored to determine the correlation between PBR exercises and fall risk in the aging adult. Additional research is needed to examine the correlation between core strength/ stability and fall risk in the aging adult, if any.

CONCLUSION This case report illustrates that increases in core stability developed from a PBR program may lead to clinically important changes on functional fall risk assessments in an aging adult who sustained a hip fracture due to a fall. Pilates-based rehabilitation exercises can be an important component of a comprehensive rehabilitation program for a frail and complex aging adult.

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