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  • Tip Falls Risk Prediction Template

    Hi,

    I'm new to this group but I wonder if this is the appropriate forum to try out some new ideas.

    I've created a Falls Prediction Template, using a 'quantitative approach' as described by Ganz. I've supplemented Dr. Ganz's work with typical PT-tests as described by Shumway-Cook that most of us will recognize.

    We use the template clinically but also for Medicare compliance, arguing for longer episodes of care based on '82% chance of future falls risk', for example.

    The template is objective and predictive - I've attached a .pdf for comment.

    Let me know if this is helpful or if another forum might be more appropriate.

    Thanks,

    Tim
    Attached Files
    Tim Richardson, PT
    www.PhysicalTherapyDiagnosis.com

  • #2
    Tim, I don't understand how you can have an "Infinite" +LR with using an assitive device.

    Could you please explain that?

    I also have some difficulties with this way of "Quantifying" risk but I won't go into that...

    Comment


    • #3
      One limit of these fall risk assessments is that there seems to be an assumption that the person being testing is going to do all the things being done in the tests. That is, the risk assessment is accurate given the patient actually tries to do those things. However, a lot of patients specifically avoid doing the types of things the test requests of them and thus their actual risk of falling down is greatly diminished. To enhance the usefulness of these tests, there should be some sort of consideration for patient decision making/judgement.

      Dementia begins to get at this but is a sufficiently generic consideration so as not to yield patient specific information. For example, I've had patients with dementia that walked about as much as they're allowed while others won't ambulate unless compelled or coerced.

      The behavioral component is one of the main challenges in fall prevention programs.

      p.s. Tim, this is a nicely referenced tool with useful information. Consider introducing yourself in the Welcome Forum.
      Last edited by Jon Newman; 09-01-2010, 02:01 AM.
      "I did a small amount of web-based research, and what I found is disturbing"--Bob Morris

      Comment


      • #4
        Tim,

        Do you have the bibliography for the citations?
        "I did a small amount of web-based research, and what I found is disturbing"--Bob Morris

        Comment


        • #5
          Hi, Tim. Glad you're here at Soma Simple.:thumbs_up

          I don't understand the first row with the medications list and those + and - LRs in the next two columns. What does that mean?

          And I'm with Gilbert on the infinite +LR for use of an assistive device. Wouldn't that mean that if you use an assistive device you will definitely experience a fall? I've used crutches before, and I didn't fall.
          John Ware, PT
          Fellow of the American Academy of Orthopedic Manual Physical Therapists
          "Nothing can bring a man peace but the triumph of principles." -R.W. Emerson
          “If names be not correct, language is not in accordance with the truth of things. If language be not in accordance with the truth of things, affairs cannot
          be carried on to success.” -The Analects of Confucius, Book 13, Verse 3

          Comment


          • #6
            John and Gilbert,

            The likelihood ratio is a logarithmic function which means as the LR increases it becomes ever closer but never reaches the asymptote (vertical axis).

            Bottom line, the shift in likelihood will never be greater than 50%. Note that +LR for some tests are very high (27 for anti-depressants, ~25 for TBC manipulation rule) but the shift is still on the order of 50%.

            To calculate the +LR devide the sensitivity of a test by 1-specificity.

            It sounds complex but LR never gets more complicated than this simple math. An excellent book is Evidence Based Physical Diagnosis by Steven McGee, MD.

            John, you didn't fall when you were on crutches (thank goodness) and so you 'beat the odds' (odds ratios are similar to likelihood ratios).

            Again, these quantitative predictive models are based on probability theory - we can never know something for certain but we can get a very good idea at how UNcertain we are of a test or measure. We can minimize the uncertainty by selecting better tests.

            Tim

            PS: The reference list cited for the Falls Template is at www.BulletproofPT.com

            Tim
            Tim Richardson, PT
            www.PhysicalTherapyDiagnosis.com

            Comment


            • #7
              Looks good Tim, didn't see the Jim Beam test. When I was in the Navy we had a lot of those:angel:.

              Comment


              • #8
                Why Patients at risk for falls reduce their activities?

                This addresses Jon's remark

                Originally posted by Jon Newman View Post
                One limit of these fall risk assessments is that there seems to be an assumption that the person being testing is going to do all the things being done in the tests.

                That is, the risk assessment is accurate given the patient actually tries to do those things.

                However, a lot of patients specifically avoid doing the types of things the test requests of them and thus their actual risk of falling down is greatly diminished. [/url].
                Jon, one of the biggest drivers of chronicity and disability (~30% of the variability in outcomes) is Fear-Avoidance Beliefs (FAB). FAB is measurable and objective.

                Patients don't do the activities you referenced because they may be afraid of the consequences (eg: pain, falling down).

                Physical therapists can address the psychosocial aspects of our patients' disability with "brief psycho-educational strategies that can address the cognitive and affective processes that motivate pain-related activity avoidance."

                Jon, your patients with dementia that walked about independently, why was that so? What was different about them? Did they have fewer impairments and physical limitations than the other patients?

                Tim
                Tim Richardson, PT
                www.PhysicalTherapyDiagnosis.com

                Comment


                • #9
                  Hi Tim,

                  Those that walk around do so because they can and they have some desire for which walking is necessary to fulfill. I can't always say definitively why the other end of the spectrum doesn't. Sometimes it's clear that they lack some sort of strength or ROM prerequisite by the time I see them.

                  Where did the FABQ come into this? Is the FAB just a tangential reference or is it being used in fall risk assessment now? Do you have a citation for the following?

                  one of the biggest drivers of chronicity and disability (~30% of the variability in outcomes) is Fear-Avoidance Beliefs (FAB).
                  I'm familiar with the ABC but haven't used it lately. I've also tried the Falls Efficacy Scale in the past but again, not lately. Have you ever used it?

                  Patients don't do the activities you referenced because they may be afraid of the consequences (eg: pain, falling down).
                  For many patients, this is a very reasonable/accurate fear to have. That is, they make an accurate self-assessment.
                  Last edited by Jon Newman; 10-01-2010, 02:38 AM.
                  "I did a small amount of web-based research, and what I found is disturbing"--Bob Morris

                  Comment


                  • #10
                    Why Patients at risk for falls reduce their activities?

                    Jon,

                    FAB came in when you mentioned that patients avoid doing the types of things that we test for in PT:
                    gait velocity - crossing streets alone
                    squatting, kneeling - home and self care (cleaning)
                    single leg support - turning, pivoting
                    Rhomberg (tandem standing) - small spaces
                    unstable surfaces - beaches, parks, outdoors
                    visual deficit - nighttime
                    ABC test - confidence for all of the above

                    Confidence and FAB are part of the larger construct we call psychosocial factors that may account for up to 30% of the variability in orthopedic outcomes.

                    I use the ABC although scoring is tedious. I have used Modified Falls Efficacy Scale as well. Right now, the FABQ is mandated for every patient that comes in to the clinic (it's universal) - I choose a region or condition-specific measure after I've evaluated the patient.

                    Tim
                    Tim Richardson, PT
                    www.PhysicalTherapyDiagnosis.com

                    Comment


                    • #11
                      Tim,

                      Did you link to the right study? The study you linked cited job task enjoyment as a significant predictor and didn't mention fear-avoidance beliefs in the abstract. I haven't read the article to see if it's in there.

                      I want to clarify my original point in case I didn't make my point clearly. I can't tell if I did.

                      Let's take the Berg Balance Test for example. Placing a foot upon a step without external support, tandem standing, picking an item up off the floor are some of the things that are tested and doing them poorly earns a lower score and elevated fall risk. However, it seems to me that if people always use hand rails going up and down steps, use a long handled reacher or other method of retrieving items from the ground and avoid standing in tandem, that their actual fall risk is much less than if they routinely tried those things but were, in fact, terrible at performing them.

                      There doesn't seem to be any accounting for the patient's insight to their own limitations and subsequent compensation for those limitations in predicting whether they actually fall.
                      "I did a small amount of web-based research, and what I found is disturbing"--Bob Morris

                      Comment


                      • #12
                        link to FAB study

                        Jon,

                        The Boeing study (1991) is a large, influential study that was among the first to quantify the influence of psychosocial factors on the outcomes of musculoskeletal disorders.

                        Gordon Waddell, MD didn't publish his seminal article on Fear Avoidance Beliefs until 1993 but that was already an upgrade from his earlier model, simply called 'Illness Behaviour' (1987).

                        I would agree with you that Berg Balance Test pigeonholes patients in order to classify fallers from non-fallers so we can direct treatment to the high-risk group.

                        If the goal is to standardize testing, reduce unwarranted and expensive practice variation and, ultimately, reduce falls-related disability how would you recommend physical therapists alter Berg and other tests?

                        Tim
                        Tim Richardson, PT
                        www.PhysicalTherapyDiagnosis.com

                        Comment


                        • #13
                          Smith,

                          That test also has an infinite +LR (if applied often enough). Don't make the mistake of using that test with the Vehicle Operation Test (VOT) because then Medicare audits will be the least of your worries.

                          BTW, I was never in the Navy but we did do a few crazy things in the Boy Scouts - I can't go into details as this is a public forum (ahem) - 'nuff said.

                          Tim
                          Tim Richardson, PT
                          www.PhysicalTherapyDiagnosis.com

                          Comment


                          • #14
                            Originally posted by TimRich View Post
                            I would agree with you that Berg Balance Test pigeonholes patients in order to classify fallers from non-fallers so we can direct treatment to the high-risk group.

                            If the goal is to standardize testing, reduce unwarranted and expensive practice variation and, ultimately, reduce falls-related disability how would you recommend physical therapists alter Berg and other tests?

                            Tim
                            I don't think the Berg pigeon holes people. In fact, proper use of the Berg, from my understanding, predicts who is unlikely to fall. That is, if your balance is sufficiently good, there is no reason to think you'll fall over doing everyday thing. I think this is a prudent use of fall risk assessments due to the concerns I've already expressed. I suppose if there was any alteration it would be to ask the person whether they can do the items (and whether they do them) prior to testing.
                            "I did a small amount of web-based research, and what I found is disturbing"--Bob Morris

                            Comment

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