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Improving older adults' balance and preventing falls.

Abstract

Best practices for physical activity interventions within recreational therapy programs will optimize balance and prevent falls among older adults and include strength, flexibility, endurance, and balance training. This protocol describes a community-based intervention to reduce falls for older adults.

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The older adult population in the U.S. is growing rapidly. Between 1990 and 2010, there was a 13 percent increase in the number of people aged 65 and older and this number is expected to be 77.2 million by 2040 (U.S. Bureau of the Census, 2010). According to the Centers for Disease Control and Prevention (CDC) more than one-third of adults aged 65 and older fall each year with 20% to 30% of these individuals experiencing moderate to severe injuries, such as hip fractures or head traumas (CDC, 2012). Falls may reduce one's independence and increase the likelihood of premature death (CDC). Falls not only cause physical harm, they also create an immense economic burden to society. The CDC compiled the cost of all falls and estimated it to be $27.3 billion and projected these costs to rise to $43.8 billion by 2020 (CDC). Older adults are disproportionately affected by falls, as they are hospitalized five times more often with fall injuries than other causes (CDC, 2011). Of all fall-related fractures, hip fractures result in the greatest number of deaths, lead to the most severe health problems, and reduce quality of life (CDC, 2012). Using fall prevention interventions as part of recreational therapy programs may decrease the risk of falls and fractures among older adults (Bruce, Devine, & Prince, 2002). Thus, fall prevention programs appear to have a needed role in comprehensive recreational therapy services with older adults.

This community-based fall prevention intervention with older adults was designed to promote physical activity, reduce the fear of falling, and reduce falls. These are important recreational therapy (RT) goals for this population. The fall prevention intervention was developed using the scientifically based fall prevention program, FallProof![c] (Rose, 2010). The intervention was implemented in a small group format, two times a week, for 50 minutes, over eight weeks. Each session began with a 5-10 minute warm-up with older adults sitting in chairs, focusing on posture, with an exercise progression for balance and mobility following. The second edition of FallProof! A Comprehensive Balance and Mobility Training Program follows the recreational therapy process of assessment, planning, implementation, and evaluation with comprehensive tools for screening, placement, and both formative and summative evaluations to create a strong evidence-based fall prevention program with older adults (Rose). Thus, this program (Rose) was the foundation for the fall prevention intervention shared in this article. A systematic review and meta-analysis of randomized clinical trials of fall prevention interventions with older adults concluded that interventions to prevent falls in older adults are effective in reducing the risk of falling and the monthly rate of falling. The most effective intervention was a multifactorial falls risk assessment and management program combined with physical exercises (Chang, Morton, Rubenstein, et. al., 2004). The FallProof! program includes each of these aspects as did the fall prevention intervention described below.

Theoretical and Evidence-based Foundations

Balance is the ability to maintain bodily equilibrium (Holbein, Billek-Sawhney, Elizabeth, & Smith, 2005). Two important components impacting balance are:

1) base of support (what contacts the floor, chair, bed etc.) which often has multi-contact points such as standing on two feet or sitting in a chair with feet touching the floor, and

2) center of gravity which is typically the upper or lower trunk and is the postural center for the body (Rose, 2010).

Effects of aging include but are not limited to decreased sensations, decreased mental ability, reduction in the loss of organ function, diminished bone and muscle mass, and decreased physical fitness ability (CDC, 2012). Some of the processes and declines associated with aging can be minimized and reduced with fall prevention interventions (Clemson et. al., 2004).

Several risk factors associated with falling among older adults that were considered when implementing this fall prevention intervention. These include:

Physical Factors. Aging in adults may include sarcopenia (muscle weakening and shrinking), slow shuffling walk, lower body weakness, poor grip strength, balance disorders, functional impairments, cognitive impairments, visual deficits, high blood pressure, high cholesterol, and obesity. However, many of the physical factors of aging can be reversed when older adults take proactive, preventative measures.

Muscular Strength. Aging may be associated with a decrease in muscle strength (Baumgartner, 2000) specifically lower body strength, which increases one's risk of falling due to its effect on balance (Lord & Surnieks, 2005). Research strongly supports the importance of lower-body muscle strength and endurance for dynamic balance or lower extremity physical performance.

Flexibility. The range of the joints in their full motion is important as aging occurs. There are many factors that occur with age that contribute to the decline in flexibility such as range of motion in ankle and hip joints (Rikli & Jones, 2001). Studies in older adults have shown that continued flexibility training enhances range of motion and reduces stiffness (Cress, et al., 2005).

Sensory and Motor Control. There are three main sensory systems involved in maintaining balance: the visual (eyes), vestibular (inner ear), and somatosensory (position in space) systems (Kochera, 2002). The eyes aid in balance through receptors that are sensitive to light and other external, visual references. In healthy individuals, when light strikes the eyes, impulses are sent to the brain that provide visual cues that aid in balance. Within the inner ear, there is a vestibular apparatus that consists of receptors that detect minute changes in fluid displacement and send information to the brain regarding this motion. The somatosensory system, also known as proprioception, contains receptors within the muscles and joints that send impulses to the brain that indicate movement. The sensory inputs from the eyes, ears, and muscles are sent to the brain where they are integrated and sent back to the muscles to control movement and actions (Shumway-Cook & Woollacott, 2001). Reductions in the three main sensory systems occur with advancing age (Kochera). Postural stability is important for walking, standing, sitting, and daily living activities, and often changes with age (Shumway-Cook & Woollacott). There is little or no risk of losing balance while standing if postural stability is maintained. Changes in these systems may diminish the feedback from their postural control centers; however, when postural stability is improved, older adults will reduce their risk of falling (Holbein, Billek-Sawhney, Elizabeth, & Smith, 2005).

Medications. As age increases, chronic diseases and medication may increase which can add to the likelihood of falls (World Health Organization, 2009). For example, antidepressants are highly linked to falls and it has been reported that individuals over the age of 75 with depression are nearly two times more likely to fall than those without depression (Neutal, Perry, & Mawell, 2002). Moreover, individuals taking multiple medications, including psychoactive drugs, blood pressure medications, and diuretics appear to have an increase in fall risk (Neutal, Perry, & Mawell).

Fear of falling. Fear of falling may lead to restriction of physical activity and this may affect up to 30% of the older adult population (Lord & Sturnieks, 2005). This fear may contribute to sedentary lifestyles and a reduction in mobility and balance capabilities in older adults (Lord & Sturnieks).

Buettner and Martin (1995) discussed a model fall prevention program for long-term care residents. According to their work, 47% of residents die during their hospital stay after a fall. They concluded all health care professionals, including recreational therapists, should be alert to and aware of the risks associated with falls in older adults in this setting and know how to prevent them. According to Buettner and Martin it is imperative that recreational therapists become involved in coordinating fall education programs, monitoring and alleviating risks in programming areas, and implementing comprehensive programs that help to prevent falls. Recreational therapists can have a significant impact on preventing this potentially life threatening problem among older adults in a variety of settings.

Ward (2011), a Certified Therapeutic Recreation Specialist (CTRS), completed a study evaluating the effectiveness of FallProof!, a home-based DVD program in improving balance, select functional fitness parameters, and balance-related self-confidence among community dwelling older adults who were identified as being of moderate to high risk of falling. Eighty-one older adults were assessed for fall risk using the Fullerton Advanced Balance (FAB) scale. Self-perceived balance confidence was measured by using the Balance Efficacy Scale (BES) and lower body strength and flexibility were also assessed pre- and post-intervention. Ward utilized the Self-Determination and Enjoyment Enhancement Therapeutic Recreation Model (Dattilo, Klieber, & Williams, 1998) as a foundational theory for building her intervention. Her premise was if participants experience enjoyment during his/her leisure activities, functional abilities will improve. While this was a pilot study, Ward concluded, while participants' compliance varied in completing the FallProof! program, after 12 weeks, the intervention group showed greater improvement in FAB and BES scores and feelings of competence, autonomy, and enjoyment than the control group.

While fall prevention interventions have been encouraged as part & recreational therapy services with older adults in various settings, limited interventions have been created, implemented, and validated. The discussion of this intervention hopefully will lead to expanded fall interventions with older adults implemented by recreational therapists.

Client and Intervention Protocol Background

This intervention was created to improve older adults' balance focusing primarily on multi-factorial fall risk assessment and management that includes environmental modifications, education pertaining to risks and medications, and exercise. Several studies have shown that physical activity can improve balance and reduce risk of falling in older adults (Clemson, et al., 2004; Ward, 2011). However, there is no evidenced-based "best" exercise program to prevent falls. Research demonstrates there should be a well-rounded mixture of endurance, strength, flexibility, and balance exercises within a fall prevention intervention (Robataille et al., 2005).

The aim of this recreational therapy intervention was to improve older adults' physical performance, reduce their fear of falling, and reduce falls. If older adults learn strategies and skills to reduce the risk of falling, then they may be able to continue participation in desired leisure and life activities. Moreover, how older adults perceive life situations and experiences (e.g., fear of falling) may also affect their coping skills and their ability to adapt, further influencing their ability to perform activities of daily living and leisure. Maintaining leisure and life activities, in turn, promotes successful aging (Headley, 2009). These aspects were needed outcomes and benefits of RT programs with older adults living in the community.

Recreational therapists need to obtain older adults' health history information and informed consent when offering physical activity programs. The American College of Sports Medicine provides examples of these documents in their Guidelines for Exercise Prescription (Cress et al., 2005). Recreational therapists may find other standardized assessments more useful and they also may be collecting the needed data through other formats, if their agencies are providing other types of physical activity interventions. During this fall prevention intervention, older adults were provided information on the following topics: medication usage, environmental (home and community) safety, the importance of regular vision and hearing check-ups, and key aspects of general physical assessments. Education and health promotion may be the responsibilities of RT program with older adults who live in the community. In this intervention physical functioning was assessed using the eight-foot Up-and-Go assessment, gait analysis, and Chair Stand test to obtain client baseline data. Comprehensive Evaluation in Recreational Therapy (CERT)--Physical Disabilities and the Functional Independence Measure (FIM) scale, while often used in rehabilitation and long-term care settings, may provide baseline data, if they are part of the agency's assessment process. There is no need to duplicate or replicate assessment of older adults' physical functional measures, if they are being assessed as part of recreational therapy or other therapy programs or services.

The "Checklist for Assessing Fall Risk" was used in this intervention and reports medication usage, underlying illness, sensory performance such as eyesight, and functionality (see Table 1, American Medical Directors Association, 2008). The Berg Balance Scale and the Multi-Directional Reach Test were used in this intervention as they are reliable and valid tests which are easy to administer to assess client's balance (Scott, Donaldson, & Gallagher, 2003). The Balance Efficacy Scale (BES) was also used as it is designed to evaluate the client and his/her confidence when performing activities of daily living (ADLs) and fear of falling (Rose, 2010). The BES was developed for use with the FallProof! program and has been demonstrated to be reliable (Gunter, et al., 2003). Included in the FallProof! program (Rose) are a number of assessments and instruments related to the fall prevention intervention that can be used to gather client information and functioning to create evidence-based interventions. This intervention used the validated functional assessments that are part of the FallProof! program (Rose).

This fall prevention and physical exercise intervention with older adults was delivered in small groups of 10 to 15, taking into consideration each person's abilities, in community older adult centers. Older adults engaged in group exercises using a multi-dimensional and multi-factorial approach, including center-of-gravity control, multisensory, postural strategy, gait, strength, endurance, and flexibility training. The frequency was twice weekly for 50 minutes, sessions were delivered over eight weeks. Careful consideration was given for falls and cardiac emergencies when planning and implementing this fall prevention intervention. Recreational therapists were trained in Cardiopulmonary Resuscitation (CPR), Automated External Defibulation (AED), and First Aid prior to delivering the intervention. Rooms for the intervention were prepared in advance considering lighting, flooring, furniture, and restroom accessibility. All observed obstacles that might endanger older adults were removed. A list of equipment used during this intervention is provided in Table 2. Individual adaptations were essential for maximum participation in this intervention.

The FallProof! program was used to design this intervention as it is a research-based approach to fall prevention intervention. The comprehensive manual was used in the certification program offered by the Center for Successful Aging at California State University at Fullerton. This program is recognized as a "Best Practice" by the Health Promotion Institute of the National Council on Aging (Rose, 2010). The training and manual provided the recreational therapist who created this intervention with the theoretical background along with practical steps to design and implement an intervention to improve balance and mobility along with a fall prevention educational component. Recreational therapists must receive the FallProof! training prior to implementing the program. The training provides an additional certification for the therapists (Rose).

Intervention Protocol Implementation

The FallProof! program is designed to strengthen balance and mobility among older adults. The package includes a practical training guide and DVD to support implementation. While modifications were made to this program, this intervention adhered closely to the second edition of FallProof! (Rose, 2010). The screening and assessment tests included in FallProof! were used as pre-and post-tests with this intervention as it was important to determine the efficacy of this intervention with the targeted older population. The reproducible forms and checklists provided the instructor with tools to determine the efficacy of this intervention and data to support its sustainability. In this specific intervention, older adults were tested before beginning the intervention and then eight weeks later, at the end of the program. This intervention demonstrated improvement scores on the Balance Efficacy Scale as well as other physical assessments.

The FallProof! (Rose, 2010) manual discussed program planning and class management techniques which were useful before and during each session. Additionally, the manual highlighted sound educational materials related to fall prevention and then provided in-depth materials and illustrations of multidimensional balance and mobility exercises along with how these can be adapted to meet the abilities of various older adults. These illustrations were helpful in making modifications for various older adults during the intervention. For instance, some participants became bored with the exercises using the bean bags. The exercise was needed, so participants were introduced to a parachute with handles and interest was renewed. Safety, exercise efficacy, and participants' interests and needs were addressed at every phase of intervention implementation. Age, fitness level, health history, personal goals, and likes and dislikes played a large role in selecting the mix of educational and exercises sessions to prevent falls among older adults. During this intervention, the instructor was always mindful of the older individuals who had expressed the greatest fear of falling and offered adaptations when introducing specific exercises. Physical exercises were selected to be difficult enough to challenge each participant, yet not so hard as to risk injury, cause fear, or discourage participation. This notion is demonstrated in the following session examples:

1. Getting up from a fall

Educating older adults about falling improved their understanding of the fall itself, what to do during a fall, and how to get up after a fall. Sensory and motor control along with balance exercises focused on stability and coordination while challenging strength reserves and built confidence. Using props simulated different surfaces that older adults walked on and offered illustrations of how to transition them safely in an engaging fashion. There were incidents when it appeared an individual would need help getting up after a fall and various alarm devices were discussed.

2. Improving ankle, hip, and gait stability and strength

Observing how older adults walked, climbed stairs, and bent over to pick up things challenged them to explore and change behaviors that improved stability and balance control by building strength. Older adults often needed specific techniques to strengthen their ankle and hip muscles which promoted gait stability. During the intervention, one older participant shared she feared she would fall coming into her home from the garage as there was a small step. This situation was replicated and specific exercises were created to improve gait related to entering her home. In another cases, as the individual practiced picking up items off of the floor, it was clear balance was so poor a fall could easily occur; thus, a "grabber/reacher" was introduced and shared with all participants. The individual found this device extremely helpful while she worked on building balance.

3. Multisensory training

When implementing this fall prevention intervention with older adults, balance threshold was constantly stressed in order to improve dynamic balance and neuromuscular efficiency or coordination. By utilizing multisensory training in a dynamic environment older adults gained understanding and skills in the multi-domains of balance control. All of the older adults participating in this fall prevention intervention began in static postures and positions. Developing participants in the more dynamic environments that modeled their everyday lives and situations in which they were prone to fall, such as walking over obstacles, came later in the sequencing of the intervention and was found to be beneficial and motivating as they progressed. Several participants progressed rapidly and served as role models for others.

FallProof! has been shown to yield positive results in reducing the fear of falling and in increasing physical and psychosocial benefits in older adults (Gunter, et al., 2009). This intervention demonstrated statistical significance in participants when compared with a control group. Those receiving the intervention improved in balance and in reducing their fear of falling over those who participated in a physical exercise program without the prevention aspects. On-going evaluation of specific fall prevention interventions with specific older adults is needed.

Summary

Preserving physical function and preventing falls among community-dwelling, older adults is a public health concern and can be an area of focus for recreational therapists. There are several factors that affect a person's balance including age, medications, senses, strength, and flexibility. Although there is no proven "best" exercise prescription or fall prevention intervention that works in all cases, a multi-faceted fall prevention approach, such as FallProof!, which was used in this intervention, demonstrated recreational therapists can help to improve balance and reduce older adults' fears of falling. Continued study is needed in the recreational therapy profession related to fall prevention interventions in various settings and with older adults who have various physical, cognitive, and psychosocial abilities.

Learning Outcomes: The reader will be able to:

1. Identify at least 1 consequence of falls for older adults.

2. Describe a benefit to a fall prevention program as a part of RT.

3. Identify at least 4 risk factors for falls among older adults.

Questions: Please select the most appropriate answer.

1. What percent of falls result in moderate to severe injuries?

a. <10%

b. 20-30%

c. 40-50%

d. >50%

2. Costs related to falls are projected to be __ by 2020.

a. 27.3 billion

b. 27.3 million

c. 43.8 billion

d. 43.8 million

3. Of all fall related fractures, these lead to the most severe health problems:

a. Shoulder

b. Pelvis

c. Ankle

d. Hip

4. This fall prevention intervention was based on which program?

a. Activities and Balance Program

b. Fall Proof!

c. Fall NO More!

d. Balance for Seniors

5. The length of time for this fall prevention intervention is:

a. 2x/week for 50 minutes, for 8 weeks

b. 4x/week for 50 minutes, for 4 weeks

c. 2x/week for 30 minutes, for 8 weeks

d. 4x/week for 30 minutes, for 4 weeks

6. True or false: According to the article, antidepressants are highly linked to falls.

a. True

b. False

7. To obtain appropriate baseline data for clients enrolled in this intervention, which of the following is a recommended assessment tool?

a. Chancellor Balance Scale

b. Activities Balance Scale

c. Balance Confidence Scale

d. Up and Go

8. The article recommends testing individuals in this program:

a. At pre- and post-intervention

b. At 4, 6, 8, 12 weeks

c. Once per month

d. At baseline only

9. True or false: The Fall Proof! Program is evidence-based.

a. True

b. False

10. True or false: The Fall Proof! Program is identified as the gold standard in exercise for older adults.

a. True

b. False

References

American Medical Directors Association (AMDA). (2008). Clinical practice guidelines: Fall and fall risk. Columbia, MD: AMDA.

American Medical Directors Association (AMDA). (1998). Checklist for assessing fall risk and post-fall review. AMDA's Clinical Corner: Falls and Fall Risk, Retrieved from www.amda.com/clinical/ falls/figure_1.htm

Baumgartner, R. N. (2000). Body composition in healthy aging. Annals of the New York Academy of Sciences, 904, 437-438.

Bruce, D., Devine, A., & Prince, R. (2002). Recreational physical activity levels in healthy older women: The importance of fear of falling. Journal of the American Geriatric Society, 50, 84-89.

Buettner, L., & Martin, S. (1995). Therapeutic recreation in the nursing home. State College, PA: Venture.

Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. (2012). Falls Among Older Adults: An Overview. Retrieved from http://www.cdc.gov/ HomeandRecreationalSafety/Falls/adultfalls.html

Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. (2011). Costs of Falls Among Older Adults. Retrieved from http://www.cdc.gov/HomeandRecreationalSafety/ Falls/fallcost.html

Chang, J., Morton, S., Rubenstein, L., Mojca, W., Moylione, M., Suttorp, M. et al. (2004). Interventions for the prevention of falls in older adults: Systematic review and meta-analysis of randomized clinical trials. British Medical Journal, 328(7441), 680. doi:10.1136/bmj.328.7441.680

Clemson, L., Cummings, R., Kendig, H., Swann, M., Heard, R., & Taylor, K. (2004). The effectiveness of a community-based program for reducing the incidence of falls in the elderly: A randomized trial. Journal of American Geriatrics Society, 52, 1487-1494.

Cress, M. E., Buchner, D. M., Prohaska, T., Rimmer, J., Brown, M., Dipietro, L., et al. (2005). Best practices for physical activity programs and behavior counseling in older adult populations. Journal of Aging and PhysicaI Activity, 13(1), 61-74.

Dattilo, J., Kleiber, D., & Williams, R. (1998). Self-determination and enjoyment: A psychologically-based service delivery model for therapeutic recreation. Therapeutic Recreation Journal, 32, 258-271.

Gunter, K. B., DeCosta, J., White, K. N., Hooker, K., Hayes, W. C., & Snow, C. M. (2003). Balance self-efficacy predicts risk factors for side falls and frequent falls in community-dwelling elderly. Journal of Aging and Physical Activity, 11, 28-39.

Headley, C. M. (2009). Examination of N'Balance, a community-based fall prevention intervention for older adults (Doctoral dissertation). University of Illinois, Urbana- Champaign, IL.

Holbein, J., Billek-Sawhney, B., Elizabeth, E., & Smith, T. (2005). Balance in personal care home residents: A comparison of the Berg Balance Scale, the Multi-Directional Reach Test, and the Activities-Specific Balance Confidence Scale. Journal of Geriatric Physical Therapy, 28(2), 48-53.

Kochera, A. (2002). In brief: Falls among older persons and the role of the home: An analysis of cost, incidence, and potential savings from home modification. Public Policy Institute Issue Brief #56. AARP. Retrieved from http://www.aarp. org/home-garden/home-improvement/info-2002/ aresearch-import-797-INB49.html.

Lord, S. R., & Sturnieks, D. L. (2005). The physiology of falling: Assessment and prevention strategies for older people. Journal of Science and Medicine in Sport, 8(1), 35-42.

Neutal, I. C., Perry, S., & Mawell, C. (2002). Medication use and risk of falls. Pharmacoepidemiology and Drug Safety, 11, 97-104.

Rikli, R., & Jones, C. (2001). Senior fitness test manual. Champaign, IL: Human Kinetics.

Robitaille, Y., Laforest, S., Fournier, M., Gauvin, L., Parisien, M., Corrivewu, H., et al. (2005). Moving forward in fall prevention: An intervention to improve balance among older adults in real-world settings. American Journal of Public Health, 95(11), 2049-2056.

Rose, D. (2010). Fallproof!: A comprehensive balance and mobility training program. Champaign, IL: Human Kinetics.

Scott, V., Donaldson, M., & Gallagher, E. (2003). A review of the literature on best practices in fall prevention for residents of long-term care facilities. Long Term Care Falls Review, September, 1-29.

Shumway-Cook A., & Woollacott, M. H. (2001). Motor control: Theory and practical applications. Philadelphia: Lippincott Williams & Wilkins.

U.S. Bureau of the Census. (2010). Population projections program, population division. Retrieved from www.census.gov/population/www/projections/ popproj.html.

Ward, K. (2011, February 8). RT news line: A publication of the Recreation Therapy Section of California Parks & Recreation Society. Sacramento, CA: Retrieved from http://seniorexercisevideos.net/ blog/?m=201102

World Health Organization. (2009). Global health risks: Mortality and burden of disease attributable to selected major risks. Geneva: World Heath Organization.

Catherine M. Headley, Ph.D.

Judson University

M. Jean Keller, Ph.D., CTRS

University of North Texas

Catherine M. Headley, Ph.D., Department Chair and Associate Professor for the Exercise and Sport Science department at Judson University, Elgin, IL. She conducts research investigating fall prevention programs in the community. She coordinates the Senior Circuit, a multi-dimensional physical activity program for older adults.

M. Jean Keller, Ph.D., CTRS, Professor, University of North Texas, Department of Kinesiology, Health Promotion, and Recreation. Her research has focused on programming with older adults along with fall prevention programs.
Table 1
CHECKLIST FOR ASSESSING FALL RISK

Factors                Fall Risk

Falls history          [] Does client have a history of falling?

Underlying illnesses   Does client:
and problems           [] have underlying medical condition(s) that
                          predispose him/her to falls (i.e. dementia)?
                       [] have history of orthostatic hypotension?
                       [] have underlying medical condition(s)
                          affecting balance, causing dizziness or
                          vertigo (i.e. inner ear disorder)?
                       [] have underlying medical condition(s) that
                          augment injury risk from falls (i.e.
                          osteoporosis)?

Medications            Is client taking:
                       [] medications predisposing him/her to falls?
                          (i.e. diuretics, cardiovascular
                          medications, anti-hypertensives,
                          antipsychotics, anti-anxiety agents,
                          sleeping medications, anti-depressants)

Functional Status      Does client:
                       [] have impaired mobility, standing or sitting
                          balance?
                       [] have impaired ability to use ambulatory
                          supporting device (cane, walker, etc.)?
                       [] wear supportive footwear?

Sensory Status         Does client:
                       [] have impaired vision (i.e. cataracts,
                          glaucoma, macular degeneration)? Have
                          impaired hearing (i.e. wears hearing aid)

Note: Adapted in part from the American Medical Director's Association
"Clinical Practice Guideline: Falls and Falls Risk"
http://www.amda.com/clinical/falls/figure-1.htm, 2008.

Table 2
BALANCE KIT INVENTORY

Equipment                    Amount

Lightweight balls            6
3 small
3 large

Balance balls                5
1 55-cm
2 65-cm
1 75-cm
1 80-cm

Large ball holders           5

Weighted balls               3
1 kg ball
2 kg ball
3 kg ball

Dyna-Discs                   4

Stacking cones               Set of 30

Nested benches               2 sets
2,4,6-inch

Thin foam mats               4

Airex balance pads           2

Half foam roll               4
6 X 36 inches
12 X 36 X 0.5 inches

Agility spots                2 sets of 10

Resistance bands             5

Air inflator or compressor   1

Popsicle sticks              25

Laundry basket               2

Large Rubbermaid             2
container

Parachute with handles       1

Bean bags                    20

Mesh bag                     1

Masking tape                 2

Stop watch                   2

NOTE: Adapted in part from FallProof![c]
(Rose, 2010).
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Title Annotation:EVIDENCE-BASED PROTOCOL
Author:Headley, Catherine M.; Keller, M. Jean
Publication:Annual in Therapeutic Recreation
Date:Jan 1, 2013
Words:4715
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