Falls Risk Screening and Assessment Skills for the Student Physical Therapist

Falls Risk Screening and Assessment Skills for the Student Physical Therapist
By Helen Buchanan, SPT

Background
Falls risk screening and prevention have been passions of mine for a long time. I also intend to work with older adults after graduating and have a lot of experience in caring for older adults at risk for falls, particularly my grandparents. I also have an interest in teaching/lecturing and enhancing the student experience to best prepare for the clinical environment, therefore I wanted to combine these interests when formulating my capstone.

Prior to physical therapy school, I had a wonderful experience assisting Tiffany Shubert, PT, PhD with her research investigating the use of the Otago Exercise Program in a virtual platform to identify changes in physical performance measures associated with falls risk.¹ This research fueled my interest in screening and assessment for falls risk and desire to understand common changes in the older adult that contribute or could be modified to decrease risk.

During physical therapy school, I have been fortunate to work with Carol Giuliani, PT, PhD, FAPTA conducting Senior Fitness Testing at the Passmore Senior Center in Hillsborough, NC, as well as providing screens during the Falls Prevention/Awareness Day in 2019 at the Seymour Senior Center in Chapel Hill, NC. Conducting similar testing as a part of two courses within the DPT program at UNC further exposed me to methods of falls risk screening and prevention while allowing me to critically think about interventions and assistance PTs can provide within the older adult population.

Though not all falls are preventable, there is much we as physical therapists can do to lessen risk and improve safety and quality of life as adults age. Through this capstone experience, I wanted to share clinical pearls and updated evidence while engaging PT students in screening and assessment methods to foster increased knowledge in working with older adults at risk for falls.

Statement of Need
Falls are the leading cause of injury in older adults age ≥65 years with approximately 29 million reported falls in 2014 and at least 1 in 3 resulted in injury.² An estimated $31.3 billion in Medicare costs is allocated to care related to falls, which is expected to increase as the older adult population grows by potentially 55% by 2030, adding the potential for 48.8 million falls annually with 11.9 million fall injuries.² While not all falls are preventable, a key component to preventing falls among older adults is to recognize individuals at risk for falls through appropriate screening and assessment techniques.^3,4 Physical therapists are in a unique position to administer this screening and assessment while playing an integral role in the management of modifiable risk factors.

Core courses of the UNC DPT curriculum, PHYT 736 (Physical Therapy for Older Adults) and PHYT 701 (Motor Development and Human Movement Across the Lifespan), involve lecture and lab components addressing falls risk screening techniques, assessment, prevention, and intervention in older adults. Common critiques of these experiences includes students’ desire for greater exposure to testing measures, application of knowledge based on case presentations, and more discussion of clinical experience with the older adult population.

As DPT1s, PHYT 701 content acts as an introduction to physical therapy for the older adult in regard to changes across the lifespan, with a focus on general effects of aging, risk factors and implications of falls in the older adult, and screening tools to begin the assessment of falls risk in the older adult. Typically, DPT1 students are able to apply this introductory knowledge in screening independent-living older adults at Carol Woods Retirement Community with portions of the Senior Fitness Test and Berg Balance Scale while sharing that data with Carol Woods staff to make fitness recommendations for residents. However, the 2020 COVID-19 pandemic made this experience impossible to safely conduct in-person. Therefore, increasing student participation with case study discussion and providing access to online video demonstrations of testing strategies with key explanations was a necessary component in addition to updated lecture materials.

As DPT2s, PHYT 736 is intended to increase knowledge of physical therapy approaches with the older adult population while strengthening evidence-based clinical reasoning skills when working across a variety of settings. Focusing lecture content on screening versus assessment and using clinical reasoning to determine an appropriate plan of care based on evaluative findings prepares DPT2 students for the Carol Woods lab experience as well as upcoming clinical rotations. Providing updated psychometrics data and application of outcome measures associated with falls risk allows the students to determine appropriate application of tests during lab and interpret results to guide potential interventions. The PHYT 736 lab previously matched content from the 701 experience at Carol Woods, involving SFT and Berg testing of community-dwelling residents of which the Carol Woods staff also used the data as previously stated. To expand the value of the experience, adding contact with older adults requiring higher levels of support (HLOS, i.e. assisted living) with greater involvement of a variety of conditions (e.g. musculoskeletal, neurologic, etc.) allows students to further demonstrate their knowledge in approaching care for the older adult.

Purpose
The purpose of this capstone is to expand the knowledge and practice of DPT students within UNC’s program with updated evidence regarding falls risk screening and assessment by physical therapists, at the respective expected levels of clinical reasoning and application of DPT1 and DPT2 students. Updating lecture material that introduces DPT1 students to the physiologic effects of aging, contributions to falls risk, and screening, assessment, and intervention techniques relevant to the older adult allows students to utilize this knowledge in a case discussion. By incorporating a literature review of outcome measures proven effective to assess falls risk into the lecture components with a focus on psychometrics investigated since 2012, DPT2 students are able to apply this knowledge in selecting an appropriate tool to screen an older adult as well as discuss potential interventions across the spectrum of levels of care within the population.

Products
In total, 2 lectures, 1 lab, and 1 case discussion were delivered to students in UNC’s DPT program.

For PHYT 701, the DPT1 students were provided a lecture encompassing Aging and the Older Adult in the VoiceThread format due to the transition to online-learning during COVID-19. After viewing the VoiceThread, DPT1 students participated in a case discussion via Zoom that focused on obtaining subjective information, identifying potential impairments based on case data and lecture material, discussing modifiable factors and appropriate interventions in light of safety concerns and falls risk, and recognizing appropriate referrals that could assist in providing an interdisciplinary approach to the care of an older adult.
• PHYT 701 Aging and the Older Adult lecture materials
• PHYT 701 Aging and the Older Adult VoiceThread
• PHYT 701 Case Discussion Talking Points

For PHYT 736, the DPT2 students were presented a lecture concerning screening and assessment of falls risk in older adults and updated psychometrics of 6 outcome measures proven effective to assess falls risk (evidence published since 2012). Outcome measures included the Berg, Tinetti Performance Oriented Mobility Assessment (POMA), Dynamic Gait Index (DGI), Fullerton Advanced Balance Scale, Balance Evaluation Systems Test (BEST), and Mini-BEST. Following the lecture, DPT2 students conducted screening and assessment of multiple residents at Carol Woods in both community-dwelling and HLOS settings with the goal to use clinical reasoning to select an appropriate outcome measure based on resident presentations/concerns in addition the original testing components of the SFT used by staff. The DPT2 students then presented a case based on the results of testing one older adult, integrating their clinical reasoning behind their choice in outcome measure, and discussing potential interventions and referrals integrated into a plan of care for that case. Though not formally part of my capstone therefore not included on this website, viewing these presentations affirmed the increased knowledge as my objective for the students based on their presented clinical reasoning, use of outcome measures, and application of material.
• PHYT 736 Falls Risk Screening and Assessment Skills lecture

Evaluation
Prior to conducting the DPT2/PHYT 736 lecture and lab and the DPT1/PHYT 701 VoiceThread, feedback was solicited from my committee advisor and members. Constructive critique was worked into the presentation to produce the final products and additional evidence was reviewed as necessary.

Following delivery of each component, DPT1 and DPT2 students were asked for feedback via surveys relevant to that component.

DPT1s completed a survey following viewing the VoiceThread lecture and participating in the case study discussion via Zoom. Overall, DPT1 students demonstrated understanding of the material, felt the lecture and case discussion illustrated the content well, and appreciated the inclusion of clinical experience that could be applied to their own practice in the future.
• DPT1 VoiceThread and case discussion student evaluation results

DPT2s completed surveys following the lecture and the Carol Woods lab experience. Overall, DPT2 students felt the lecture and lab experiences were beneficial to their learning and that they could apply their newly gained knowledge to their upcoming clinical experiences and future practice.
• DPT2 lecture student evaluation results
• DPT2 lab student evaluation results

Self-Reflection
Working with students in the Classes of 2021 and 2022 was a very rewarding experience. Looking back on my time in PHYT 701 and PHYT 736 as a first- and second-year student, while the experiences were beneficial, I found myself wanting more as a student and wanted to try to give that to those who came after me. Working closely with Carol Woods staff to arrange a meaningful experience for both the students and residents was an eye-opening experience, noting the details and arrangements that have to be made ahead of time for a full-day lab. Expanding the Class of 2021/current DPT2 students’ exposure to older adults living in Carol Woods’ HLOS residences was a fantastic addition and prompted greater clinical reasoning when assessing and discussing potential interventions in this population. I am disappointed the Class of 2022/current DPT1 students were unable to take part in the Carol Woods lab experience with community-dwelling residents, however their application of knowledge in the case study discussion proved they met their learning objectives and will be able to apply these skills in person in the future.

Overall, I am extremely pleased with how my capstone turned out. I believe I have provided resources that can continue to be used in the respective courses while also opening up experiences with current community partners to engage students with older adults as part of the curriculum. I thoroughly enjoyed the teaching aspects of my capstone and hope to continue that in some capacity following my graduation so that I can continue to update the materials and provide even greater clinical knowledge as I progress in my career.

Acknowledgements:
Thank you to my capstone advisor, Vicki Mercer, PT, PhD and my committee members Tiffany Shubert and Carol Giuliani. Your guidance and constructive feedback were invaluable throughout this process.

Vicki, your care and understanding as well as thoroughness in reviewing my products was greatly appreciated. You encouraged me to dig deeper into the research and helped me find succinct ways to say meaningful information to students.

Tiffany, thank you for taking me on to teach a lecture in your class, lead a lab, and help guide students through the presentation process from this learning opportunity. Your experience and knowledge both in and beyond the classroom helped me grow as an instructor and a clinician.

Carol, thank you for trusting me to take on a part of the curriculum you lead for so many years and adapt it to improve the student experience. Thank you for facilitating relationships with Carol Woods and for all your guidance throughout my PT journey at Carolina.

I would also like to thank Cathy Howes, PT, DPT, MS, PCS for allowing me to teach a lecture in your class and lead a case discussion. Your advocacy for your students is inspiring and I was lucky to be a small part of your course. And thanks to Dana McCarty, PT, DPT, PCS, C/NDT for helping me adapt this lecture to the online-learning environment in the wake of the COVID-19 pandemic.

Thank you to the Classes of 2021 and 2022 for being attentive during my lectures, for your participation in your respective experiences, and for your constructive feedback throughout your coursework relevant to my capstone. You all demonstrated professionalism and compassion with great ideas you can apply when working with older adults on your clinical rotations!

Finally, I would like to thank the staff and residents at Carol Woods for their partnership and willingness to work with UNC DPT students every year. The use of your facilities and working with your residents allows UNC students to gain incredible practice and real-world experience that will help form their clinical reasoning and application of skills, helping future clients/patients in the years to come!

References:

1. Shubert TE, Chokshi A, Mendes VM, et al. Stand Tall-A Virtual Translation of the Otago Exercise Program. J Geriatr Phys Ther 2018. doi:10.1519/JPT.0000000000000203.
2. Bergen G, Stevens MR, Burns ER. Falls and Fall Injuries Among Adults Aged ≥65 Years – United States, 2014. MMWR Morb Mortal Wkly Rep. 2016;65(37):993-998. doi:10.15585/mmwr.mm6537a2.
3. Centers for Disease Control and Prevention. STEADI – Older Adult Fall Prevention. 2019. Available at: https://www.cdc.gov/steadi/index.html.
4. Gillespie LD, Robertson MC, Gillespie WJ, et al. Interventions for preventing falls in older people living in the community. Cochrane Database Syst. Rev. 2012;(9):CD007146. doi:10.1002/14651858.CD007146.pub3.