An introduction to exercise-based interventions for improving balance and preventing falls among community dwelling older adults
A guide for first year physical therapy students
by Caitlin Gallagher, SPT
How my capstone project came to be…
There were several driving forces behind the development of my capstone project. In the first year of the program I identified a desire among my fellow DPT students to have greater exposure to clinical interventions prior to beginning the first clinical experience at the end of the first year. I knew that I would need to refine and specify the scope of my capstone project, however I decided early on that I wanted to share intervention-based information with first year students in preparation for their first clinical rotation.
During my second year of PT school, I developed a strong interest in working with older adults, especially in the context of active aging. I found myself repeatedly coming back to the mantra that aging is not synonymous with decline. In the spring of my second year I was lucky to have a wonderful clinical experience at a continuing care retirement community where I had ample opportunity to work with older adults. During that clinical rotation I really enjoyed treating patients who had balance impairments and I was intrigued by the many ways physical therapists can intervene to improve balance and prevent falls among older adults. I became particularly interested in understanding how well balance practice translates into functional gains. I found myself challenging my patients with cognitive tasks during their balance and gait activities to simulate real-world demands, and I became curious about the effectiveness of dual task balance interventions in the older population. These experiences helped me to form the clinical question for my Critically Appraised Topic (CAT) in Evidence-Based Practice II in the fall of the third year.
Clinical Question: For a community dwelling older adult (60 yrs or older) with an identified increased risk of falls, is dual-task balance training as effective or more effective at reducing falls risk, as compared to single task balance training?
For those of you interested in the topic, I have made my CAT available.
Over the last year I have also had a growing interest in teaching, and I would like to be involved in the education of physical therapy students as my career develops. The final capstone project presented a wonderful opportunity for me to develop an interest in teaching whilst providing first year physical therapy students with a stronger background in physical therapy interventions. Specifically, I felt that interventions related to fall prevention and older adults would be particularly relevant given the aging population. A survey completed by 49 current second and third year students confirmed a need for guidance related to interventions for balance and fall prevention among older adults.
Survey results
51% reported they saw older individuals/individuals at risk of falls “very often” during their first clinical
35% reported they saw older individuals/individuals at risk of falls “sometimes” during their first clinical
14% reported seeing older individuals/individuals at risk of falls either “rarely” or “never” during their first clinical
94% of the students surveyed felt that a brief, simple introduction to balance interventions would have been helpful to prepare for the first clinical rotation
These survey results suggested that an introduction to balance interventions would be well received by first year students. The dual task focus of my CAT was too detailed to be appropriate for first year students, however it served as a great starting point for developing an educational module related to exercise based interventions for improving balance and preventing falls among older adults.
The Project
The educational module that I developed for my capstone project includes a Voicethread presentation, a summary handout, and a short series of discussion board posts. The Voicethread includes a brief review of physiologic changes related to aging and falls risk factors, an overview of the evidence behind exercise based interventions for improving balance and preventing falls, and considerations for the long term planning of exercise-based fall prevention. At the end of the Voicethread there is a short case scenario that demonstrates application of the topics. The summary handout is meant to be a quick reference for the major topics covered in the Voicethread. The discussion board posts are designed to allow students to practice selecting appropriate interventions based on case scenarios. The module was integrated into the course: Motor Development and Human Movement Across the Lifespan (PHYT 701). Students are able to access the materials online and complete the module over the course of a couple of weeks. The timing of the module coincides with the course content related to aging, and the final discussion post requires students to apply the material from the module to the Adult and Older Adult Movement Lab.
Evaluation and self-reflection
In an effort to make my educational module more user-friendly, I reviewed “Keys to designing effective presentations” by Margaret Plack. I have included a short description of my application of presentation guidelines and strategies for this educational module.
Students were asked to complete a post module survey, to assist in revising the module for future use. The results of the survey and feedback from the students is described in the Evaluation document.
Overall, it seems as though the module was well received, however, if I am given the opportunity to implement it again, I would make several changes based on the feedback I have received from students. First, I would love to have part of this module be delivered in an in-person format, however that was not a feasible option at this time. I think a live presentation and case scenario discussion would alleviate some of the criticisms surrounding the Voicethread, and it be an opportunity to have more interaction with the students. If a Voicethread were used in the future, I would record it again, at a slightly faster pace, editing out any redundant comments and possibly inserting video clips/links of various exercise progressions or formats (tai chi, etc). For the discussion posts, I would change the final “older adult lab post” into a group post or I might work with the course instructor to have a question included in the lab write-up, so that student’s could complete it more easily and in a collaborative manner. Also, I think it would be helpful to have multiple cases on the initial and response discussion posts, so that students can apply the concepts in different ways without feeling like it is redundant busy work (everyone answering about the same case). Also, many of the students worked with very active, healthy older adults in the older adult lab, so additional cases may be beneficial to apply the concepts in more “realistic patients”.
My capstone project has been a wonderful learning experience for me. I have a newfound appreciation for the effort that is required to create a useful and comprehensive teaching module. I have appreciated the opportunity to utilize teaching tools such as Voicethread and Sakai discussion board postings. Additionally, I have gained greater appreciation for how to develop instructional materials in a way that effectively reaches the target audience. This has also been an opportunity for me to receive constructive criticism and to evaluate how to better meet the needs of students. I hope that this is just the first of many teaching experiences for me!
Acknowledgements
I would like to say a big thank you to my committee members Andy Blackburn and Carol Giuliani for sharing their expertise in working with older adults, and for helping me to develop a project that was clinically relevant and appropriate for first year students. Also, thank you to my advisor Karen McCulloch who helped me create a cogent plan for implementing my project. I would also like to thank Melissa Scales for allowing me to integrate this project into her course this spring (PHYT 701)- I appreciate that you were flexible and willing to make sure this module fit in well with the older adult content of the course. Finally, thank you to the UNC DPT students in the Class of 2017 for allowing me to share my capstone project with you!
5 Responses to “An introduction to exercise-based interventions for improving balance and preventing falls among community dwelling older adults”
Karen McCulloch
Great work on this project Caitlin – you identified and clarified the need and did a super job of creating something that improves activities already part of the curriculum to help students prepare for their summer clinicals. Love it!
I’ll be sending you additional FB by email, but am very pleased with how this all played out. Also, want to hear about your clinical this summer. Hope it is awesome!
kmac
Caitlin Gallagher
Brittany-
It is interesting that you would ask about older adults with cognitive impairment and balance training. My readings were not focused on this particular subgroup, and in fact, in many studies I read, cognitive impairment was listed as part of the study exclusion criteria. I chose to focus my readings and projects on community dwelling older adults, and while this did not specifically exclude older adults with cognitive impairment, it really reduced the amount of information I was exposed to regarding this population. For older adults with cognitive impairment, there is great concern about falls. In my Voicethread presentation I really tried to emphasize the importance of ensuring the patient’s safety during exercise both in the clinic and at home. For adults with cognitive impairment, I think this concern about safety increases dramatically. There made need to be greater modifications and simplifications to an exercise program, especially depending on the severity of the cognitive impairment, however I imagine the physical benefits of exercise (balance, strength, walking, etc.) are comparable. I think further investigation into balance training for adults with cognitive impairment would be another great topic to explore, and would certainly be clinically useful. I hope to find myself working with older adults in the future, and I think that exploring balance training/multi-component exercise for fall prevention with cognitively impaired older adults would be a great topic for an in-service or evidence based presentation in that type of setting.
Thanks for your interest in my project!
Caitlin
Carol Giulani
Thank you for identifying this need in our curriculum. I am certainly aware of the increased older adults PTs see across the spectrum of care, but really hadn’t addressed how the first year students may not be adequately prepared for their first clinic. I think you have a good balance of content for PHYT 701 that seems to blend well with the current content for that course. I think of geriatric pts as more complex with multiple comorbidities and chronic conditions. I have avoided using too many geriatric examples or papers on geriatrics in PHYT 751. I will take the information you provided and rethink that approach! Just a note on the voice thread, volume a bit too low, hard to understand some of your comments, or maybe just age.
Brittany Stapleton
Hey,
I enjoyed reading your capstone site. This information is critical to know since the older population is expected to grow rapidly. I worked at senior centers and I often implemented multi-component interventions to improve the client’s balance. It is good to know that evidence supports this. I did not complete core exercises with them and may consider adding core exercises when appropriate in the future. I reviewed your voicethread and I found the presentation easy to follow and the pictures helped grab my attention. During your research, did you find any resources related to balance training in older adults with cognitive impairment? If you were treating a patient with mild to moderate cognitive impairment, how would you change your approach?
Brittany
Jonathan Samuelson
Hi Caitlin-
I enjoyed reading you project. Having done my project on functional exercise for older adults, I found your project to be somewhat related in that preventing falls and increasing function/balance is a primary aim of exercise for older adults, in general. Having trained older adults over the years, I agree with the statement that aging should not mean a necessary decline.
Your handout was extremely helpful in highlighting the interventions used for balance and falls prevention. You made it very clear that a multi-intervention strategy is the optimal way to tackle balance impairments and prevention of falls. Including the relevant outcome measures on the handout with the web-site will certainly be of benefit to students. Another outcome measure that might be relevant would be the Dynamic Gait Index (DGI).
The case study on the 83 year old woman you provided is a good way to have students actively think about the problem and solutions. I find that going through a scenario is a more effective way for me to learn as opposed to just seeing or hearing the presentation material alone.
Jonathan