Outpatient Physical Therapy Intervention for a 74-Year-Old Female With Balance Deficits

due to Weakness, Decreased Balance Confidence, and Cervicogenic Dizziness

Author: Jeffrey D. Snyder

Research Advisor: Linda M. Hall PT, MS, DPT

Doctoral Program in Physical Therapy

Central Michigan University
Mount Pleasant, Michigan

April 3, 2024

Submitted to the Faculty of the

Graduate Program in Physical Therapy at

Central Michigan University

In partial fulfillment of the requirements of the

Doctorate of Physical Therapy

Accepted by the Faculty Research Advisor

Linda M. Hall PT, MS, DPT

Linda M. Hall PT, MS, DPT

Date of Approval: April 3, 2024

 ABSTRACT

Background and Purpose

Falls among elderly populations are incredibly common and are a main contributor to increases

in morbidity and mortality, as well as loss of independence as we age. Studies have shown that

the incidence of falls being 59% among elderly women and 71% among elderly men. Falls can

be caused by a combination of factors including progressive muscular weakness, impaired

balance, and an increased fear of falling. Physical therapy interventions focused on improving

balance and lower extremity (LE) strength are often a primary strategy for preventing falls in

elderly populations at an increased risk; however, there is limited research available of the effect

of physical therapy for patients with a combination of muscular weakness, impaired balance,

intermittent cervicogenic dizziness, and significantly decreased balance confidence. The purpose

of this case report is to describe individualized physical therapy interventions and their effect on

balance, functional mobility, balance confidence, and dizziness in a patient with balance deficits

due to a variety of factors.

Case Description

A 74-year-old female patient presented to outpatient physical therapy treatment with balance

deficits due to LE weakness, decreased balance confidence, and intermittent cervicogenic

dizziness. The patient reported a history of recurrent falls and a significant fear of falling when

ambulating in her community. The patient was evaluated using a variety of outcome measures to

test her muscular strength, balance, functional mobility, and possible vestibular deficits. The

patient was found to have significant deficits in strength, functional mobility, balance, and

balance confidence and was deemed appropriate for physical therapy intervention consisting of
an individualized treatment program focused LE strengthening, balance, gait training, and

manual therapy.

Outcomes

Upon discharge from physical therapy after 15 treatment sessions including the initial evaluation,

the patient displayed improvements in her LE strength, functional mobility, balance,

cervicogenic dizziness symptoms, and overall balance confidence. The patient’s overall LE

strength and Timed Up and Go (TUG) scores improved significantly. The patient also reported

significant improvements in her Activities-Specific Balance Confidence (ABC) and Dizziness

Handicap Inventory (DHI) scores and improved her Berg Balance Scale (BBS) score to no

longer be considered at a high risk of falling. Lastly, the patient reported that her cervicogenic

dizziness symptoms drastically improved after the second week of therapy. The patient met

nearly all her functional mobility and balance goals at the time of her discharge.

Discussion

The patient’s outcomes at the time of discharge were both similar and different when compared

to the current available research. The patient showed significant improvements in her balance,

functional mobility, and balance confidence which is comparable to the findings of multiple

research studies. The patient differentiated from much of the available research in that there were

a variety of factors that may have been contributing to her impaired balance, while much of the

research available is specific to other patient populations and impairments. There is a general

lack of research on the effects of individualized physical therapy intervention for patients with

impaired balance due to weakness, decreased balance confidence, impaired functional mobility,

and intermittent cervicogenic dizziness, therefore further large-scale research is required to

determine the best approach to treating patients such as the one described in this report.
Background and Purpose

Falls are incredibly common among elderly populations and result in a high probability

of morbidity, mortality, and loss of independence as we age.1 A survey of elderly people in the

United States showed that the incidence of falls was 59% in women and 71% in men, with 17%

of both men and women suffering from recurrent falls.2 Another study found that the percentage

of older adults who fall increases with age.1 Falls in elderly populations are more likely to cause

fractures, sprains, and other injuries that result in a loss of independence and an increased burden

on the healthcare system.2 Falls in elderly populations across the world can be caused by a wide

variety of factors, including progressive muscular weakness, fear of falling, difficulties with

static and dynamic balance, certain medical conditions, and more.1 One study conducted by

Gazibara et al. found that most falls occur while walking, and a significant fear of falling, as well

as being a woman, were both independent risk factors for increased falls in elderly populations. 3

While this data could be skewed because research has shown women are more likely to report

falls than men, it is commonly accepted that having a fear of falling drastically increases the risk

of falling.1

To prevent falls in elderly populations, it is important that we understand why someone

may be at an increased risk of falling based on their individual presentation. As stated earlier,

risk factors for falls can be attributed to a wide variety of medical diagnoses, impairments,

functional deficits, and personal factors.1 Some of the most significant risk factors for falls

include a general fear of falling, having history of falls, impaired balance, decreased balance

confidence, and medical diagnoses or medications that may cause dizziness or vertigo. 4 While

medical management of conditions that may increase a patient’s risk of falling is important,

1
studies have shown that due to the multifactorial nature of fall risk it is crucial for patients to

receive individualized, interdisciplinary care that is focused on fall prevention. 1

Physical therapy is often a primary treatment option for elderly patients who have deficits

that increase their risk of falling. Physical therapy interventions centered around balance and

strengthening are often a focus in this patient population due to impaired balance caused by

weakness and other factors being a primary risk factor for falls. A single blinded randomized

controlled trial conducted by Stanghelle et al. studied the effects of a physical therapy exercise

program focused on resistance and balance training on physical fitness, health-related quality of

life, and fear of falling in elderly women with osteoporosis.5 The study included 149 women

aged 65 years and older who were diagnosed with osteoporosis. The intervention group

performed a 12-week exercise program focused specifically on muscular strengthening and

balance training.5 Outcomes used for the study included walking speed, functional reach, quality

of life surveys, and fear of falling.5 The study found that walking speed did not improve;

however, fear of falling improved substantially, therefore proving that muscular strengthening

and individualized balance training can improve balance confidence and fear of falling in elderly

women with increased risk of falling.5

Another study conducted by Miko et al. studied the effects of a 12-month long balance

training exercise program on postural stability, aerobic capacity, and frequency of falls in older

women with osteoporosis.6 While the patient described in this case study did not have

osteoporosis, many of the deficits described in the study conducted by Miko et al. and the

outcome measures used were very similar to those seen in the patient. The study included 100

older women with osteoporosis who were split into an intervention group and a control group,

with the intervention group performing the balance exercise program three times per week for

2
twelve months. Outcome measures used in the study included the Timed Up and Go (TUG), the

Berg Balance Scale (BBS), and stabilometric platform tests. After the twelve-month program

was complete, the study concluded that there were significant improvements in all outcome

measures in the intervention group.6 This study has revealed that balance training has a positive

impact on postural balance and aerobic capacity in elderly women with osteoporosis.6

Lastly, a study conducted by Giardini et al. studied the effects of different types of

balance training on balance and gait performance in patients with Parkinson’s disease. 7 While the

patients in this case did not have Parkinson’s disease, this study is relevant because many of the

patients in the study had similar impairments and similar outcome measures were used. The

study involved 32 patients with Parkinson’s disease who performed a variety of balance

exercises.7 The outcome measures used in the study for balance included the Index of Stability,

and the Mini-BESTest, while outcome measures for gait included the TUG and baropodometry.

The study's results found significant improvements in both balance and gait in patients who

performed standardized balance exercises and those who performed exercises on a moving

platform. The study concluded that balance training is beneficial for not only balance, but for

gait as well in patients with Parkinson’s disease.7

Overall, there is limited research on the impact of physical therapy interventions on

patients who suffer from a combination of deficits including balance, gait, and diagnoses such as

cervicogenic dizziness. After review of the literature, there are also very little to no case-based

studies on physical therapy interventions for patients with deficits similar to that of the patient in

this study. Available research has proven that strengthening, balance training, and gait training

can significantly improve balance, gait, and fear of falling in patients with ranging diagnoses.

The purpose of this case report is to describe individualized outpatient orthopedic physical

3
therapy interventions and their effect on balance, functional mobility, balance confidence, and

dizziness in a 74-year-old female with balance deficits due to weakness, decreased balance

confidence, and cervicogenic dizziness.

Prior to preparing this report, consent was obtained from the patient to proceed. All

information contained in this case report meets the Health Insurance Portability Accountability

Act (HIPAA) requirements of the clinical agency for disclosure of protected health information.

This case report was completed in accordance with procedures approved by the Institutional

Review Board at Central Michigan University.

Case Description

Patient History and Systems Review

The patient is a 74-year-old female who presented to physical therapy after being referred

by her primary care provider with complaints of balance deficits. The patient reported feelings of

imbalance and unsteadiness for the past year that have progressed and become complicated by

the insidious onset of intermittent cervicogenic dizziness. The patient reported weakness in her

legs which had forced her to be cautious when walking in her home and in the community to

avoid falls. She stated that she often required additional time performing functional tasks, such as

climbing stairs, walking, and performing activities of daily living because she was afraid that she

would fall due to her weakness and dizziness. Prior to the onset of these symptoms, the patient

had no functional limitations.

The patient described her balance deficits being especially prominent during instances

while she was ambulating outdoors, when there was nothing obstructing her peripheral vision,

and when she was required to perform quick head turns. The patient gave walking on her dock as

an example of an experience she felt especially unsteady. She explained that her symptoms had

4
progressively worsened over the past year and that she was recently experiencing sporadic

cervicogenic dizziness for two months that had further affected her balance and confidence with

ambulation. The patient reported multiple falls in the recent past, one of which resulted in a

broken femur for which she required surgery and physical therapy. The patient reported a

significant fear of falling after having falls in the past. At the time of evaluation, her main

concern was losing her ability to perform functional tasks and being unable to spend time with

family and friends. She expressed therapy goals of improving her balance confidence and ability

to walk safely in the community by improving her lower extremity (LE) strength and eliminating

her feelings of dizziness and unsteadiness.

A review of systems was performed, and the patient’s past medical history consisted of

hypertension (HTN), benign paroxysmal positional vertigo (BPPV), and a right femur fracture

requiring surgery two years prior to evaluation. She also had a history of smoking and tobacco

use and was educated on smoking cessation. The patient reported no other significant past

medical history. The patient lived alone in a one-story condominium with two steps to enter with

bilateral railings. She said her daughter and son-in-law lived nearby and could provide support if

needed. The patient was retired and reported spending most of her time with family and friends

and being active around her community. The patient’s medications are listed in Table 1.

Clinical Impression #1

Upon a detailed review of the patient’s medical history, review of systems, prior level of

function, and reason for physical therapy referral, it was expected that the patient would have

multiple impairments that would affect her mobility and limit her ability to participate in

activities of daily living (ADLs). Due to patient subjective reporting and history of falls, it was

expected that the patient would have impairments in LE strength, static and dynamic balance,

5
gait speed, balance confidence, and functional mobility. The examiners were also aware of the

possibility of the patient having vestibular deficits due to her history of BPPV. These possible

impairments could limit the patient’s ability to perform activities such as community ambulation

and ADLs and further impair her confidence. Activity limitations such as these could restrict the

patient’s participation in community activities, social interaction, and hinder her ability to spend

time with her family.

It was determined by the examiners that testing would be performed to quantify the

patient’s exact deficits to guide the plan of care. A general screen of ROM, strength, sensation,

and proprioception would be performed to determine specific areas of impairment that required

further, more detailed examination. Each impairment determined by the general screen would be

further tested using a variety of evidence-based outcome measures. All outcome measures, how

they were performed, and the evidence to support them are listed in detail in the examination

section of this report. It was expected after subjective evaluation that the examiners would likely

need to perform outcome measures to assess strength, vestibular function, balance, gait, and

balance confidence. For example, balance would be assessed via the Berg Balance Scale (BBS),

balance confidence would be assessed using the Activities-specific Balance Confidence Scale

(ABC), and gait speed/functional mobility would be assessed using the Timed Up-and-Go

(TUG) test.

The preliminary physical therapy diagnosis for this patient was impaired functional

mobility and safety with community ambulation and activity due to bilateral LE (BLE)

weakness, impaired static and dynamic balance, vestibular deficits, decreased balance

confidence, and decreased gait speed. After subjective interview of the patient and a review of

her past medical history, it was determined that she would be an appropriate patient for this

6
report. The patient was qualified as a unique candidate for this study due to the variety of factors

that may have been affecting her balance such as confidence, vestibular function, and muscular

weakness. There is currently a limited amount of case-based research on physical treatment for

patients who have deficits due to the combination of these factors. The patient’s history of falls

and subsequent injuries further makes her an interesting candidate for study.

Examination

Strength testing. After performing a general screen of upper extremity (UE), LE and trunk ROM,

it was determined that formal testing of BLE strength was needed to determine weakness. LE

strength testing was performed using manual muscle testing (MMT) according to testing

positions and procedures described by Reese.8 Strength testing was graded on a 5-point scale in

which a score of 0 is equivalent to no evidence of contraction, and a score of 5 is equivalent to a

normal contraction through the entire test range against gravity and maximal resistance. 8 The

strength scale used, and each specific grade is listed in Table 2. Manual muscle testing

performed according to these procedures and testing positions has been proven to have good

intra-rater reliability of 0.84-0.93 and inter-rater reliability of 0.70.9 The same study found MMT

to have strong content validity.9 There is insufficient research on the minimal detectable change

(MDC) and the minimal clinically important difference (MCID) for standardized MMT on a 0-5

scale, however this muscle testing technique was chosen due to its simplicity, standardization,

and good intra-rater reliability.

Manual muscle testing was performed at the hip, knee, and ankle joints of the BLEs. Hip

testing included hip flexion, extension, abduction, adduction, internal rotation, and external

rotation. All hip manual muscle tests, other than adduction, were performed according to the

standardized testing positions and procedures described by Reese.8 Hip adduction was modified

7
to be tested with the patient sitting at the edge of the bed with their legs hanging. The examiner

placed both their hands in at the patient’s medial thighs just proximal to the knee, and the patient

was instructed to resist the examiner’s force pushing into abduction. The knee extension MMT

was performed according to Reese, however knee flexion was modified to allow for testing at the

edge of the bed. After the patient was asked to move through her available ROM at the edge of

the bed, the knee flexion test was performed by placing the knee joint at midrange and asking the

patient to resist a knee extension force applied by the examiner by pulling at the patent’s heel

just proximal to the ankle joint. All muscle tests performed at the ankle joint other than the

plantarflexion were performed according to Reese as well.8 The ankle plantarflexion test was

modified by testing at the edge of the bed and asking the patient to plantarflex her ankles one at a

time into the hand of the examiner applying resistance. Results for BLE MMT at evaluation can

be viewed in Table 3. LE MMT revealed generalized weakness throughout BLE, with the RLE

being weaker than the LLE. The patient displayed significant weakness at the hip, knee, and

ankle that was likely influencing her functional mobility and balance control with ambulation.

Balance. Due to the patient’s primary complaint being balance related, the examiners felt it

critical to examine the patient’s balance and balance confidence using a variety of outcome

measures. The first balance outcome measure performed with the patient was the Activities-

specific Balance Confidence Scale (ABC). The ABC is a subjective questionnaire developed by

Powell that asks the patient to rate their confidence performing certain daily activities from a

scale of 0% to 100%.10 The scale is divided into increments of 10%, with 0% having no

confidence at all and 100% being complete confidence in ability to perform the activity. 10 The

scale lists sixteen different scenarios and asks the patient to rate their confidence with performing

8
each activity. At the end of the scale, the total patient scores out of 1600 is divided by 16 to find

the percent of self confidence that the patient has with their balance.10

According to Freitas et al. the ABC scale has an excellent intrarater and interrater

reliability of 0.946.11 The scale was also found to have feasible content and criterion validity,

along with 81% sensitivity and 77.4% specificity with confidence scores under 67%. The ABC

scale also had 87.5% sensitivity and 82.1% specificity with confidence scores under 44%.11 The

minimal detectable change (MDC) of the ABC scale was found to be 11.28 according to

Alghwiri et al.12 There is no direct research on the minimal clinically important difference

(MCID) of the ABC scale, yet it was chosen for this patient because it is easy to administer,

objectively measures patient balance confidence, and has high reliability.

The entire ABC scale and results at evaluation and discharge for this patient are listed in

Table 4. The patient had significantly diminished confidence in performing many of the tasks

listed on the scale without losing her balance. The patient was least confident with tasks such as

walking on icy sidewalks, stepping onto and off an escalator without using the railing, and

standing on a chair to reach for an object. Her total average confidence was 46.3%, which is a

significantly low number.10 Studies show that decreased balance confidence and fear of falling

are the highest predictors of falls in elderly adults, therefore the patient was at a significantly

increased risk of falling.13 A visualization of the patients balance confidence scores at evaluation

and discharge can be seen in Figure 1.

Due to patient reports of recent cervicogenic dizziness and history of BPPV, the next

balance-related assessment administered was the Dizziness Handicap Inventory (DHI). The DHI

was administered according to Jacobson and is another subjective questionnaire that attempts to

quantify the impact of dizziness on a patient’s everyday life.14 The DHI contains 25 questions

9
divided into the sub-categories of physical, emotional, and functional aspects of dizziness and

unsteadiness.14 Each question can be answered as yes, sometimes, or no, with the answer yes

being equivalent to four points, sometimes being equivalent to two points, and no being

equivalent to zero points. At the end of the questionnaire, the points are added to determine a

total score. Any score greater than 10 points is a means for a referral to a balance specialist for

further evaluation.

According to Koppelaar-van Eijsden, the intrarater reliability of the DHI ranges from

0.81-0.99 depending on the patient population. This is considered sufficient reliability because it

is above 0.70.15 The DHI was found to have sufficient construct validity, however it was also

found to have inconsistent structural validity.15 Research on the MDC and MCID of the DHI is

limited now, but this is unimportant due to it being a patient-reported scale in which progress can

be seen through the inherent results. Despite having inconsistent validity and no data on MDC

and MCID, the DHI was chosen for this patient because it is easy to administer, can show patient

progress with dizziness, and is specific to the complaints of the patient.

The entire DHI scale and the results for the patient at evaluation and at discharge are

listed in Table 5. The patient had a total score of 28, putting her in the category of mild

handicap.14 According to the patient's reported results, she was having the most difficulty with

activities such as walking by herself and more ambitious activities like exercising. The patient

also reported that she avoids heights because of her dizziness. The results of the DHI show that

the patient had a mild handicap in her daily life due to the dizziness that she was experiencing.

The final balance assessment performed at evaluation was the Berg Balance Scale (BBS).

The BBS is an assessment developed by Katherine Berg that tests the patient’s balance with

various tasks, including static and dynamic balance.16 The examiner asks the patient to perform

10
fourteen different tasks that range from standing unsupported to performing dynamic weight

shifting and reaching. Each task is graded on a scale of zero to four, with zero often meaning the

patient required max assistance, and four being the patient was independent with the task. The

patient is scored out of 56 total points, with scores under 45 indicating that an individual may be

at a higher risk of falling.16

The BBS has been proven to have excellent interrater reliability of 0.993, as well as good

intrarater reliability of 0.886.17 Research has also shown that the BBS has good construct and

concurrent validity.17 The BBS has an MDC of 10.5 points, along with a sensitivity of 94.4% and

a specificity of 54.8%.17 Lastly, according to Tamura et al., the MCID of the BBS in older adults

with hip fractures is 11.5 points, while a substantial change was determined to be 18.5 points.18

The BBS is a well-known and widely researched assessment that was chosen for this patient

because it is relatively easy to administer, measures static and dynamic balance, and assesses

whether a patient may be at higher risk of falling.

The entire BBS and the patient’s scores can be seen in Table 6. The patient scored 43/56,

indicating she may be at a higher risk of falling. She struggled with both static and dynamic

balance throughout the testing, particularly with tasks involving standing on one leg, reaching,

and turning her body. All these motions, especially turning and reaching, are motions required

for a variety of ADLs, and are crucial for maintaining functional independence. The patient

displayed decreased static and dynamic balance throughout the BBS that further jeopardizes her

functional mobility and increases her risk of falling while ambulating in the community.

Vestibular. Due to the patient’s history of BPPV and reports of difficulty and feelings of

dizziness with quick head turns the examiners determined it important to assess the patient’s

vestibular function. The examiners chose to perform the Dix-Hallpike maneuver to rule in or rule

11
out posterior canal BPPV. The Dix-Hallpike maneuver is considered the gold-standard for

testing for posterior canal BPPV and is widely used. The maneuver was performed according to

Talmud and involved the patient sitting upright on the examination table with her legs

extended.19 The patient’s head was then turned 45 degrees toward the side being tested and the

patient was quickly lowered down with their head hanging off the edge of the table. The position

was held for a minute and the examiner closely examined the patient’s eyes for nystagmus and

asked the patient to report any symptoms she felt. This process was performed again on the

opposite side. The test is considered positive when nystagmus is present, or the patient reports

significant dizziness.19

There is limited research on the reliability and validity of the Dix-Hallpike maneuver, but

research on its sensitivity and specificity has been conducted. According to Halker et al., the

Dix-Hallpike maneuver has a 79% sensitivity and a 75% specificity when ruling in or out

BPPV.20 There is no research on the MDC or MCID of the Dix-Hallpike maneuver because the

test is either positive or negative, rather than having a score associated with it. In the case of this

patient, she did not display any nystagmus or other symptoms associated with the Dix-Hallpike

maneuver. Therefore, despite the patient having symptoms of unsteadiness with head turns,

BPPV was not considered the primary concern in this case.

Functional mobility. Lastly, the examiners determined it necessary to test the patient’s functional

mobility at evaluation to simulate how the patient may navigate her everyday life and

environment. The Timed Up and Go test (TUG) was performed with the patient to evaluate

mobility and balance with a task functional and applicable to daily life. The TUG was performed

according to Nightingale and involved the patient standing up from a chair, walking at a normal

pace for 3 m, turning around and walking back to the chair to sit down.21 The TUG is scored

12
based on how long it takes the patient to perform the entire sequence.21 A score of greater than 12

seconds on the TUG in elderly patients indicates a higher risk of falls when ambulating in the

community.21

Research performed using the TUG has revealed the test to have excellent intrarater

reliability of 0.98.22 The test has also proven to have good concurrent validity.21 The MDC of the

TUG is 3.2 seconds, meaning the patient would have to improve their score by 3.2 seconds for

there to have been a significant change.22 Research on the MCID of the TUG is limited in

populations similar to the patient; however, research performed with patients who had lumbar

degenerative disk disease revealed the TUG to have an MCID of 3.4 seconds.23

The TUG was chosen to evaluate the patient’s functional mobility because it is simple to

administer and simulates an activity that is functional and applicable to everyday life. When

performing the TUG, the patient completed the test in 15.8 seconds, placing her in the category

of having an increased risk of falls. The patient’s gait was examined while she performed the

test, and she displayed decreased step and stride length with a narrow base of support while

ambulating. The patient was extra cautious when turning and while sitting down at the end of the

test. Due to the increased time it took her to complete the test and the gait abnormalities

observed, it was determined that the patient had significant deficits in functional mobility and

was at an increased risk of falling when ambulating in the community. A visualization of the

patient’s TUG scores at evaluation and discharge can be seen in Figure 2.

Clinical Impression #2

After thorough examination and evaluation, it was apparent that the patient presented

with significant impairments that were affecting her functional mobility and balance and were

limiting her participation in daily activities. The patient displayed weakness in BLE with

13
standardized MMT, with the LLE presenting as weaker than the RLE. The patient reported

significantly low balance confidence on the ABC scale, particularly with more difficult tasks

such as walking on ice and reaching outside her base of support. On the DHI, the patient scored

28, putting her in the mild handicap category due to her dizziness symptoms. The patient

reported significant limitations with tasks such as ambulating in her community and exercising

due to her reports of sudden dizziness. When performing the BBS, the patient was determined to

be at an increased risk of falling, particularly due to difficulty with balance during tasks such as

turning quickly and standing on one leg. With functional mobility testing, the patient was found

to be at an increased risk of falls after taking significantly longer than normal on the TUG and

displaying gait abnormalities such as decreased step and stride length. Despite complaints of

dizziness and unsteadiness with head turns and a history of BPPV, the patient tested negative

during the Dix-Hallpike maneuver with no nystagmus or increased symptoms.

The examination findings mostly matched the expectations from the initial clinical

impression, and the working physical therapy diagnosis was developed. This stated that the

patient had impaired functional mobility along with safety concerns during community

ambulation secondary to BLE weakness, decreased balance confidence, gait abnormalities, and

impaired static and dynamic balance. It was determined that the patient would be seen three days

per week for an estimated 6 weeks, with each session being an hour long. Interventions would

include LE strengthening, static and dynamic balance training, overground gait training, manual

therapy, and head turning habituation exercises. Although the patient had many impairments, she

had good rehab potential. The patient’s positive factors for recovery included her motivation to

improve, her dedication to the written home exercise program (HEP), and her family and social

14
support systems. Barriers to the patient’s rehabilitation included her living alone, and her

significant fear of falling due to her history of falls.

The patient’s goals for therapy included improving her static and dynamic balance,

increasing her LE strength, increasing her tolerance to head turns, and improving her

independence with functional mobility to be able to ambulate easily in her community and

participate in social and family events. The patient also expressed that she wanted to become

more confident in her overall balance so that she no longer feared falling and could ambulate

more frequently in the community. Interventions performed with the patient would revolve

around these goals and challenge the patient to improve her balance to ensure safe and effective

mobility in her community with minimal risk of falls. The patient continues to be a good

candidate for this case report due to the multiple impairments influencing her mobility and

balance, along with a general lack of case studies involving patients with similar deficits.

Physical therapy intervention was deemed an appropriate course of action to attempt to address

the patient’s concerns and improve her overall mobility and confidence.

Interventions

The patient participated in 15 physical therapy treatment sessions, including the initial

evaluation, over a period of 5 weeks. Treatment sessions were an hour long and included

interventions specific to the patient and focused on improving her impairments in functional

mobility, balance, ambulation, and strength. Each intervention was performed with the patient’s

impairments in mind, and interventions were progressed and regressed according to patient

tolerance. The interventions performed will be listed by category and described in detail below.

Each intervention and the sessions in which they were performed can be viewed in Table 7.

15
Throughout her time in therapy, the patient was a full participant with perfect attendance and

tolerated interventions without significant complications.

Therapeutic exercises. Throughout her time in physical therapy, a variety of therapeutic

exercises were prescribed to the patient to address her LE muscular weakness with goals of

improving strength, functional mobility, and balance. Therapeutic exercises performed with the

patient included LE strengthening, cervical musculature stretching, and aerobic exercise. These

exercises were performed to address the patient’s specific impairments, with the goal of

improving her overall balance, balance confidence, and functional mobility.

After the patient’s initial examination, it was determined that she had significant BLE

weakness that was affecting her gait and balance performance. The patient had bilateral hip,

knee, and ankle muscle weakness with the LLE weakness being more profound than the RLE. It

was deemed important by the examiners for the patient to perform hip, knee, and ankle

strengthening exercises to improve her BLE strength, gait mechanics, balance, and functional

mobility. Research has shown that lower extremity strength, including hip, knee, and ankle

strength, is correlated with improved balance in older adults.24 Another study conducted by

Hasselgren determined that LE strengthening directly influences balance performance and

functional mobility in geriatric patients.25 Other research revealed that hip and knee weakness are

related to chronic ankle instability and posterolateral balance control. 26

An example of an exercise performed by the patient was a hip strengthening exercise that

involved the patient standing next to a bar for support and performing repetitions of straight leg

hip flexion, abduction, adduction, and extension. This exercise was progressed by having the

patient perform the same exercise but with resistance in the form of a resistance band. The

patient progressed through bands of varying resistance during therapy to continue to overload the

16
hip musculature and improve strength. Many LE strengthening exercises were performed and

progressed with the patient throughout her therapy. Table 7 includes the complete list of

exercises and indicates when each was performed. The patient had increased soreness at times

with LE strengthening but tolerated the exercises well without injury or complication.

The second type of therapeutic exercise performed with the patient was cervical muscular

stretching and deep cervical flexor strengthening. At examination, the patient complained of

neck stiffness and a recent onset of intermittent cervicogenic dizziness and neck pain that had

increased her fear of falling. Cervicogenic dizziness is described by literature as a “clinical

syndrome characterized by the presence of dizziness and associated neck pain in patients with

cervical pathology.”27 Upon further examination, the patient was found to have decreased

cervical range of motion (ROM) in all directions and decreased flexibility of cervical

musculature, primarily the upper trapezius, levator scapulae, and scalene muscles. Therefore,

neck stretches targeting these muscles were performed with the goal of improving cervical ROM,

decreasing neck stiffness and pain, and improving cervicogenic dizziness symptoms. The patient

was also found to have forward head posture and decreased deep cervical flexor muscle strength

and endurance, both of which could have further contributed to the cervicogenic dizziness she

was experiencing.27 It has also been found through research that decreased neck ROM and

cervical muscle tightness can increase the patient’s cervicogenic dizziness and cause fear of

movement.28

Proper patient education about the diagnosis and therapeutic exercise, including

stretching and strengthening, has been found to be an effective treatment method for decreased

cervical ROM and cervicogenic dizziness.28 Cervical musculature stretching and strengthening

was included in almost every session, and the exact exercises and sessions they were performed

17
are listed in Table 7. Each stretch was performed for three sets of 30 second holds, and there was

no need for them to be progressed throughout therapy. Cervical retraction exercises were

performed to strengthen the deep cervical flexor muscles and were progressed by increasing

repetitions and duration.

Lastly, aerobic exercises were performed with the patient each session as a warmup to

improve patient endurance and prepare her for higher intensity exercises. The patient started each

session by riding a recumbent bicycle for six minutes with this goal in mind. The research on

warmup procedures and their benefits is scattered and contradictory, but some studies have

shown that an active warmup of aerobic exercise and stretching can improve ROM and

performance in athletes.29 Additionally, an active warmup consisting of aerobic exercise has

shown to improve short-term performance in higher intensity activity.30 Due to the patient being

an elderly woman who is not accustomed to exercising in her daily life, the examiners

determined it important for her to warmup at the beginning of each session, rather than

immediately beginning with higher intensity strengthening and balance exercises. Aerobic

exercise was progressed by increasing the workload on the recumbent bicycle over time.

Balance exercises. At the time of evaluation, the patient’s main concern was her difficulty with

balance and fear of falling. The patient reported significantly decreased balance confidence on

the ABC and scored low enough on the BBS to indicate that she is at an increased risk of falls

when ambulating in her community. The patient’s main concern was with walking outdoors and

in the community, and she expressed feeling unsteady, dizzy, and lacking confidence in her

ability to ambulate without falling. Based on patient subjective reporting and outcome measures

performed at evaluation, it was deemed necessary for the patient to perform a variety of balance

exercises and activities that would challenge her and build her balance confidence. Balance

18
interventions performed with this patient included static and dynamic activities designed to

challenge her balance while performing tasks in multiple postures and positions. The patient had

difficulty with many of the balance activities throughout therapy and claimed many of them

made her feel unsteady and uncomfortable; however, this is how the exercises were designed. To

improve the patient’s balance, she would need to be challenged and feel unsteady at times and

she tolerated the exercises well without significant complications.

Throughout her time in physical therapy, the patient performed many static balance

exercises and challenges. The human body is required to maintain balance in both static and

dynamic situations, therefore the examiners found it crucial to test and challenge the patient’s

static balance to improve her ability to maintain her posture and her balance while performing

static activity. Research has shown that static balance is a crucial component of everyday life,

and a study conducted by Jacobson indicated that independent static balance training improves

overall balance and functional mobility in elderly populations.31 Falling is the biggest cause of

accidental death in elderly populations, and a study conducted by Lai et al. states that static

balance training is an effective method for improving balance capacity and decreasing the risk of

falls in older adults.32 The examiners designed challenging static balance activities for the patient

to test her boundaries and decrease her risk of falling. An example of a static balance activity

performed with the patient is the wobble board. The patient would stand on a small board that

wobbled from side to side for three minutes. The board would wobble in an anterior to posterior

direction for three minutes and laterally for three minutes. This exercise was progressed by

having the patient narrow her base of support on the board and close her eyes while performing

the activity. Most of the static balance challenges performed by the patient were progressed in a

similar fashion. Many exercises were also modified and progressed to include quick head turns

19
performed simultaneously to the activity. Head turns were added to many exercises because

quick head turning was a primary cause of the patient’s feelings of unsteadiness with walking

and activity. All specific static balance activities and the days which they were performed are

listed in Table 7.

Along with static balance training, dynamic balance activities were developed by the

examiners to challenge the patient’s balance while performing activities that involved movement.

Many of these activities were designed with the patient in mind and focused on improving the

areas of her balance that were the most impaired such as quick turns of both her body and her

head. A few exercises given to the patient also included a reactive component to improve the

patient’s ability to react to unexpected external perturbations. A meta-analysis performed by

Lesinski et al. concluded that combined static and dynamic balance training activities is an

effective way to improve overall balance during dynamic activities in healthy older adults. 33 An

example of a dynamic balance activity performed by the patient was a backward walking

exercise that involved the patient in performing straight leg hip extensions before taking large

steps backwards. The exercise progressed throughout therapy by having the patient perform

quick head turns simultaneously while taking large steps backwards. External perturbations were

also added to increase the difficulty and variability of the activity in the form of a resistance band

around the patient’s waste held by the examiner. Research shows that perturbation-based balance

training is an effective technique to improve reactive balance in elderly adults and can

significantly decrease their risk of falling.34 A comprehensive record of all dynamic balance

activities and the sessions in which they were performed is included in Table 7.

Gait training. One of the patient’s main goals for therapy was to improve her ambulation

tolerance, speed, and steadiness so that she would be able to ambulate in her community

20
regularly. At evaluation, the patient reported that she had not been ambulating outside her home

recently due to her fear of falling and feelings of unsteadiness when walking outside on uneven

surfaces. The main goal of performing gait training activities with the patient was to work toward

her goal of being able to walk outside independently without fear of falling. A variety of gait

training exercises were performed with the patient that included both overground gait training in

the clinic and outdoor walking.

While in the clinic, the patient would be challenged through various gait training

activities that included different obstacles, steps, and hurdles. The patient’s balance would also

be challenged during these activities by having her perform frequent body and head turns while

ambulating across obstacles. The patient would participate in activities that included normal

forward walking, side stepping, and backward walking to train all aspects of the patient's gait and

prepare her for unexpected situations when ambulating independently in the community. Many

of the obstacle courses and hurdle training exercises that the patient performed were designed to

be challenging to allow the patient to make errors and force her to perform a reactive stepping

response to catch herself. Research has shown that gait and step training that was performed with

the patient improves reactive balance, overall gait, and reduces falls in older adults by 50%. 35

These obstacle course-like gait training exercises were progressed by increasing the amount and

height of obstacles, forcing the patient to perform quick turns, and providing external

perturbations to the patient. Due to the patient’s complaint of difficulty and feelings of

unsteadiness with head turning, the patient was often asked to turn her head quickly in all

directions while performing these activities.

On the days when it was possible, outdoor gait training was also performed with the

patient to simulate normal walking in her own community. Outdoor walking was a primary goal

21
for the patient, therefore the examiners found it important to create interventions that applied to

that goal. According to research, a loss of outdoor mobility in the elderly is associated with poor

health and social care outcomes.36 The patient also displayed decreased speed on the TUG that

would put her at greater risk of falls while in the community. Research has shown that decreased

gait speed is a valid predictor of fall risk in elderly populations, and that gait training

interventions should be performed with older adults with declining gait speed.37

Outdoor gait training would consist of the patient ambulating varying distances outside

with the examiner. The patient would be challenged by having to walk on uneven terrain, up and

down hills, and navigate curbs and steps. Due to poor weather some treatment days, outdoor gait

training was unable to be performed every session, but when performed the patient found it

extremely beneficial and stated that it improved her confidence significantly. After performing

outdoor gait training in therapy, the patient stated that she felt confident enough to begin

ambulating short distances outdoors independently again. Outdoor gait training activities were

progressed by having the patient ambulate longer distances, up and down hills, and over narrow

support surfaces. Dual task challenges were also added at times during outdoor gait training to

challenge the patient’s ability to maintain her gait while focusing on a distraction. All gait

training exercises and the sessions which they were performed can be found in Table 7.

Manual Therapy. Lastly, a few manual therapy exercises were performed with the patient to

attempt to relieve her neck pain and tightness, along with her intermittent cervicogenic dizziness.

The patient complained of pain and severe tightness in her cervical extensor muscles that she

believed was the culprit behind her cervicogenic dizziness. Soft tissue mobilization, along with

the stretching discussed earlier, was performed to the upper trapezius and levator scapulae

musculature to relieve this tightness. Suboccipital release techniques were also performed with

22
the patient lying in supine to relieve tension in the suboccipital muscles that may have been

contributing to her dizziness symptoms. These manual therapy techniques were performed

because research has revealed that structural and functional changes to the suboccipital muscles

are often a main contributor to cervicogenic dizziness symptoms.39 Furthermore, a study

conducted by Reid et al. concluded that manual therapy interventions should be performed on all

patients with cervicogenic dizziness and may contribute to long-term relief of symptoms. 40

Another study conducted by Yaseen determined that manual therapy is a potentially effective

treatment for cervicogenic dizziness, but more research is required.41 The patient tolerated all

manual therapy techniques well without complication and expressed that she stopped having

cervicogenic dizziness symptoms after her second week in therapy.

Patient education/home exercise program. Throughout her therapy, the patient received frequent

education from the examiners on her diagnosis, impairments, and interventions. The patient was

also given a written home exercise program (HEP) which was updated as needed. The patient

was educated on the importance of performing her HEP and was provided with frequent

education on why certain interventions were being performed. Research has concluded that

physical therapists are often not active enough in their patient education and do not involve their

patients in goal setting as often as they should.41 This could impact patient participation in

therapy and their HEP. The patient described in this report was frequently educated and updated

on her goals and was included in the conversation when setting them. The patient also required

frequent encouragement while performing activities due to her lack of balance confidence and

fear of falling. Patient education and discussion about goals occurred at nearly every therapy

session.

Outcomes

23
The patient met or made significant progress toward all goals established at evaluation

throughout the 5 weeks she spent in outpatient physical therapy. The patient’s goals were

primarily focused on functional mobility and maintaining balance while navigating her

community to avoid recurrent falls. The patient also had goals centered around eliminating her

intermittent cervicogenic dizziness symptoms and improving her confidence while ambulating in

her home and throughout her community. The patient subjectively reported being pleased with

her progress in therapy and desired to continue receiving treatment.

The patient reported that she had become significantly more confident in her balance and had

improved her functional mobility to allow her to ambulate independently with less fear of falling.

At the time of discharge, outcomes were collected for this report; however, the patient was

unable to continue therapy due to extenuating circumstances. She did report that she planned to

continue with therapy as soon as possible.

Strength

The results of manual muscle testing at evaluation and discharge can be seen in Table 3. Overall,

the patient made noticeable progress with BLE strengthening in all muscle groups tested. The

largest increases in strength could be seen with BLE hip testing. The patient increased her BLE

hip abduction from 3+/5 to 5/5, as well as her BLE hip extension strength from 3+/5 to 4/5. The

patient saw the least progress with ankle strengthening in all directions, but the patient still

scored higher at discharge on all ankle MMT besides inversion and inversion. While there is no

significant research on MDC/MCID for MMT, the patient improved her BLE strength in nearly

every test performed and did not display any regression in strength during her time in therapy.

Balance

24
At evaluation, the patient filled out subjective reports regarding her balance and dizziness. These

reports included the Activities Balance Confidence Scale and the Dizziness Handicap inventory.

The results of her report show significant improvement in both measures. The patient scored

46.3% self confidence in her balance at the time of evaluation and scored 64.4% at discharge.

The MDC for the ABC is 11.28, meaning that the patient had a significant improvement in her

balance confidence across the 5 weeks that she spent in therapy. The second subjective measure

taken was the DHI, in which the patient scored a 28 at evaluation indicating that the patient had a

mild handicap due to her dizziness. At discharge, the patient scored a 14, indicating an

improvement that no longer places her in the category of mild handicap. There is limited

research on the MDC and MCID of the DHI; however, based on subjective reports from the

patient and the improvement of her score it could be said that she experienced a significant

improvement in her dizziness symptoms that no longer impaired her functional mobility.

The final balance measure performed with the patient was the BBS. The patient scored a

43/56 on the BBS at evaluation and a 52/56 at discharge, no longer placing her in the category of

being at an increased risk of falling. The patient still required supervision with some aspects of

the test, but she made drastic improvements in therapy. The BBS has an MDC of 10.5 and an

MCID of 11.5 and while the patient did not technically meet the requirements for her changes to

be deemed statistically significant, there was a noticeable improvement in her performance on

the test and the patient stated that she believed she had made great improvements in her balance.

Vestibular/functional mobility

At evaluation, the Dix-Hallpike maneuver was performed on the patient to rule in or out

vestibular deficits such as BPPV. The test was deemed negative at evaluation and vestibular

involvement was ruled out. The test was not performed again at discharge because it was deemed

25
unnecessary, and the patient reported that her dizziness symptoms became non-existent after her

third week in therapy. Lastly, the patient performed the TUG once again before being discharged

from therapy. At evaluation, the patient completed the test in 15.8 seconds, and her score at

discharge improved to 12.3 seconds. The TUG's MDC is 3.2 seconds while the MCID is 3.4

seconds in certain populations. Based on these results, it can be said that the patient made a

significant improvement in her functional mobility with the TUG.

Discussion

The purpose of this case report was to describe outpatient orthopedic physical therapy

interventions and their results for a 74-year-old female with balance deficits due to a variety of

factors including weakness, decreased balance confidence, and intermittent cervicogenic

dizziness. The patient was seen over a period of 5 weeks for a total of 15 treatment sessions,

including the initial evaluation, at an outpatient physical therapy clinic. Physical therapy

intervention was focused on improving the patient’s specific impairments in balance by creating

an individualized treatment plan that was targeted to improve the patient’s deficits. The patient

was also educated and provided with a written HEP that was modified throughout the course of

her care. Interventions included lower extremity strengthening, balance training, overground gait

training, and manual therapy.

While case-based research on physical therapy intervention for patients like the one in

this study is limited, the outcomes of this case report represent both similarities and differences

when compared to the current literature available. The study conducted by Stanghelle et al.

studied the effects of physical therapy interventions, particularly LE strengthening and balance

activities, for elderly women with osteoporosis who were at an increased risk of falling.5 The

outcomes of the study showed that there was no significant change in walking speed across the

26
participants, but there was a significant change in fear of falling.5 While fear of falling and

walking speed were not specifically measured with the patient in this study, the patient did show

a significant improvement in her balance confidence, which could be linked to an improvement

in her fear of falling. The outcomes of this report slightly differ from the study conducted by

Stanghelle et al. because the patient displayed an improvement in functional mobility and

walking speed, evidenced by her TUG score.

Similarly, a study conducted by Miko et al. concluded that physical therapy interventions

focused on balance training can improve postural balance and aerobic capacity in elderly women

with osteoporosis.6 The outcomes of this case report are similar to the study, with both using the

TUG and BBS as outcome measures. The patient described in this study displayed significant

improvements in both the TUG and BBS with balance training included in her treatment

program. The interventions described in this report differed slightly from those used in the study

conducted by Miko et al. because balance training was not the only form of intervention

performed with the patient.

In a study conducted by Giardini et al., the researchers studied the impact of balance

training on overall balance and gait in patients with Parkinson’s disease.7 The study found that

balance training is an effective intervention for improving both overall balance and gait

performance in this population.7 While all outcome measures used in this case report other than

the TUG differ from those used in the study, the results of this report are similar due to the

patient improving her balance, gait, and overall functional mobility throughout her time in

therapy. The major difference between this report and the study conducted by Giardini et al. is

that the patient in this report did not have Parkinson’s disease, therefore the research available

does not directly apply to her.

27
 While there are similarities within the available literature and the outcomes of this report,

there are also differences between the two, along with a general lack of research available that is

directly applicable to the patient. Many of the outcome measures used in the available research

differed from those used with the patient. Additionally, most of the current research focuses on

the impact of physical therapy interventions on balance or functional mobility alone, rather than

both. Many studies that have been performed were also targeted to very specific populations,

such as patients with Parkinson’s disease or elderly women with osteoporosis. This made it

challenging to relate much of the available research to the patient in this study. Research on

physical therapy and cervicogenic dizziness is limited as well, and many of the research studies

performed did not study possible improvements in functional mobility or balance that may have

been correlated to improvements in dizziness symptoms.

There are a few possible barriers to the achievement of better outcomes in this study. One

of these barriers is the patient having to end her time in therapy before she desired. Due to

extenuating circumstances, the patient had to stop receiving physical therapy and planned on

returning in the future. Despite the patient reporting that she felt there was further progress to be

made, she was still able to be seen 15 times over a period of 5 weeks and made significant

progress. Another barrier to the achievement of better outcomes was weather. A primary goal for

the patient was to improve her community and outdoor ambulation, and to decrease her fear of

falling while walking outdoors. While outdoor gait training was performed with the patient as

often as possible, inclement weather often made it difficult or impossible to do so. The patient

may have seen even greater improvements in her functional mobility and balance confidence if

outdoor gait training specific to her needs was able to be performed more frequently.

Furthermore, the patient’s dizziness symptoms could be seen as a barrier to achieving better

28
outcomes. While the goal of therapy was to improve these symptoms, the patient’s dizziness

limited her ability to perform certain exercises at times during her initial visits. Despite her

dizziness symptoms improving within the first few weeks, they could be seen as a barrier to

achieving better functional mobility and balance outcomes due to the patient not being able to

perform or progress with exercises as quickly. Lastly, the patient living alone could be seen as a

barrier to progress due to the fact that many balance activities were not able to be prescribed in

the patient’s HEP due to safety concerns and an increased risk of falling without supervision.

While there were a few potential barriers to this study, there were also positive factors

that contributed to the progress that the patient made throughout her time in therapy. One of

these positive factors was the patient’s motivation to improve and her willingness to work hard

to achieve her goals. The patient consistently attended treatment sessions and often wanted to

stay longer to continue to perform exercises. Another positive factor for the patient was her

social support system. The patient had family that lived nearby who she saw regularly and who

encouraged her to continue with therapy. The patient’s family and friends were supportive and

were available to drive her to therapy if needed. Lastly, the patient was receiving psychotherapy

in addition to physical therapy, which she attributed to helping her improve her confidence and

fear of falling when ambulating in her community.

Despite the positive outcomes of this case report, there were a few limitations to this

study. One of these limitations is the number of outcome measures used. While all the outcome

measures used for this study were applicable, it could have been beneficial to perform additional

outcome measures that could further quantify progress. For example, additional balance and

functional mobility outcome measures could have been used to diversify the results. A quality-

of-life outcome measure could have been used as well to further quantify how physical therapy

29
affected the patient’s daily life. Another limitation to this study was the lack of a long-term

follow-up with the patient after her time in therapy. While the patient stated that she planned on

continuing with physical therapy in the future, it could have been beneficial to follow up with her

multiple weeks after her discharge from therapy to determine the long-term effects of therapy.

Further research is needed for a variety of the topics discussed in this case report. Firstly,

there is need for further research on the effects of individualized physical therapy interventions

focused on balance and gait training and their impact on overall functional mobility in elderly

patients. This research could be conducted similarly to that of this report but on a larger scale.

Further research is also needed on the declines in LE strength associated with age and their effect

on overall balance and balance confidence in elderly patients. Furthermore, there is a need for

continued research on the impact of cervicogenic dizziness on long-term balance confidence.

There is research regarding both cervicogenic dizziness and balance confidence separately and

their correlations to fall risk; however, there is limited research on how intermittent cervicogenic

dizziness may impact a person’s balance confidence with daily activities and possibly increase

their risk of falling. Lastly, further research should be conducted on how a combination of

psychotherapy and physical therapy may impact a patient’s fear of falling and balance

confidence. This case report was focused on the physical therapy treatment of a patient with

balance deficits due to LE weakness, decreased balance confidence, and intermittent

cervicogenic dizziness. The patient displayed significant improvements in functional mobility,

balance, dizziness symptoms, and balance confidence throughout her time in therapy; however,

continued, larger-scale research is required to better understand the importance of physical

therapy interventions in patient populations with similar deficits to the patient described in this

case report.

30
References

1. Cuevas-Trisan R. Balance Problems and Fall Risks in the Elderly. Phys Med Rehabil Clin N
Am. 2017;28(4):727-737. doi:10.1016/j.pmr.2017.06.006

2. Souza AQ, Pegorari MS, Nascimento JS, Oliveira PB, Tavares DMDS. Incidence and
predictive factors of falls in community-dwelling elderly: a longitudinal study. Incidência e
fatores preditivos de quedas em idosos na comunidade: um estudo longitudinal. Cien Saude
Colet. 2019;24(9):3507-3516. Published 2019 Sep 9. doi:10.1590/1413
81232018249.30512017

3. Gazibara T, Kurtagic I, Kisic-Tepavcevic D, et al. Falls, risk factors and fear of falling
among persons older than 65 years of age. Psychogeriatrics. 2017;17(4):215-223.
doi:10.1111/psyg.12217

4. Shao L, Shi Y, Xie XY, Wang Z, Wang ZA, Zhang JE. Incidence and Risk Factors of Falls
Among Older People in Nursing Homes: Systematic Review and Meta-Analysis. J Am Med
Dir Assoc. 2023;24(11):1708-1717. doi:10.1016/j.jamda.2023.06.002

5. Stanghelle B, Bentzen H, Giangregorio L, Pripp AH, Skelton DA, Bergland A. Effects of a

resistance and balance exercise programme on physical fitness, health-related quality of life
and fear of falling in older women with osteoporosis and vertebral fracture: a randomized
controlled trial [published correction appears in Osteoporos Int. 2020 Apr 27;:].

6. Miko I, Szerb I, Szerb A, Bender T, Poor G. Effect of a balance-training programme on

postural balance, aerobic capacity and frequency of falls in women with osteoporosis: A
randomized controlled trial. J Rehabil Med. 2018;50(6):542-547. doi:10.2340/16501977-
2349

7. Giardini M, Nardone A, Godi M, et al. Instrumental or Physical-Exercise Rehabilitation of

Balance Improves Both Balance and Gait in Parkinson's Disease. Neural Plast.
2018;2018:5614242. Published 2018 Mar 7. doi:10.1155/2018/5614242

8. Reese NB. Muscle and Sensory Testing, 4th Ed. St. Louis, MO: Elsevier; 2021: 1-17.

9. Rider LG, Koziol D, Giannini EH, et al. Validation of manual muscle testing and a subset of
eight muscles for adult and juvenile idiopathic inflammatory myopathies. Arthritis Care Res
(Hoboken). 2010;62(4):465-472. doi:10.1002/acr.20035

10. Powell LE, Myers AM. The Activities-specific Balance Confidence (ABC) Scale. J Gerontol
A Biol Sci Med Sci. 1995;50A(1):M28-M34. doi:10.1093/gerona/50a.1.m28

11. Freitas RM, Ribeiro KF, Barbosa JS, Gomes CDS, Deshpande N, Guerra RO. Validity and
reliability of the Brazilian activities-specific balance confidence scale and determinants of

31
 balance confidence in community-dwelling older adults. Physiother Theory Pract.
2022;38(2):345-354. doi:10.1080/09593985.2020.1747122

12. Alghwiri AA, Khalil H, Al-Sharman A, El-Salem K. Psychometric properties of the Arabic
Activities-specific Balance Confidence scale in people with multiple sclerosis: Reliability,
validity, and minimal detectable change. NeuroRehabilitation. 2020;46(1):119-125.
doi:10.3233/NRE-192900

13. Landers MR, Oscar S, Sasaoka J, Vaughn K. Balance Confidence and Fear of Falling
Avoidance Behavior Are Most Predictive of Falling in Older Adults: Prospective
Analysis. Phys Ther. 2016;96(4):433-442. doi:10.2522/ptj.20150184

14. Jacobson GP, Newman CW. The development of the Dizziness Handicap Inventory. Arch
Otolaryngol Head Neck Surg. 1990;116(4):424-427.
doi:10.1001/archotol.1990.01870040046011

15. Koppelaar-van Eijsden HM, Schermer TR, Bruintjes TD. Measurement Properties of the
Dizziness Handicap Inventory: A Systematic Review. Otol Neurotol. 2022;43(3):e282-e297.
doi:10.1097/MAO.0000000000003448

16. Berg K. Berg Balance Scale. Rehabilitation Institute of Chicago; 1989.

17. Viveiro LAP, Gomes GCV, Bacha JMR, et al. Reliability, Validity, and Ability to Identity
Fall Status of the Berg Balance Scale, Balance Evaluation Systems Test (BESTest), Mini-
BESTest, and Brief-BESTest in Older Adults Who Live in Nursing Homes. J Geriatr Phys
Ther. 2019;42(4):E45-E54. doi:10.1519/JPT.0000000000000215

18. Tamura S, Miyata K, Kobayashi S, Takeda R, Iwamoto H. Minimal clinically important

difference of the Berg Balance Scale score in older adults with hip fractures. Disabil Rehabil.
2022;44(21):6432-6437. doi:10.1080/09638288.2021.1962993

19. Talmud JD, Coffey R, Hsu NM, Edemekong PF. Dix-Hallpike Maneuver. In: StatPearls.
Treasure Island (FL): StatPearls Publishing; July 19, 2023.

20. Halker RB, Barrs DM, Wellik KE, Wingerchuk DM, Demaerschalk BM. Establishing a
diagnosis of benign paroxysmal positional vertigo through the dix-hallpike and side-lying
maneuvers: a critically appraised topic. Neurologist. 2008;14(3):201-204.
doi:10.1097/NRL.0b013e31816f2820

21. Nightingale CJ, Mitchell SN, Butterfield SA. Validation of the Timed Up and Go Test for
Assessing Balance Variables in Adults Aged 65 and Older. J Aging Phys Act.
2019;27(2):230-233. doi:10.1123/japa.2018-0049

22. Alghadir AH, Al-Eisa ES, Anwer S, Sarkar B. Reliability, validity, and responsiveness of
three scales for measuring balance in patients with chronic stroke. BMC Neurol.
2018;18(1):141. Published 2018 Sep 13. doi:10.1186/s12883-018-1146-9

32
23. Gautschi OP, Stienen MN, Corniola MV, et al. Assessment of the Minimum Clinically
Important Difference in the Timed Up and Go Test After Surgery for Lumbar Degenerative
Disc Disease. Neurosurgery. 2017;80(3):380-385. doi:10.1227/NEU.0000000000001320

24. Lapszo J, Giovanis V, Prusik K, Prusik K. Balance control contributors - the relationships
between leg strength and balance control ability in seniors. Acta Bioeng Biomech.
2012;14(3):3-8.

25. Hasselgren L, Olsson LL, Nyberg L. Is leg muscle strength correlated with functional
balance and mobility among inpatients in geriatric rehabilitation?. Arch Gerontol Geriatr.
2011;52(3):e220-e225. doi:10.1016/j.archger.2010.11.016

26. Khalaj N, Vicenzino B, Smith MD. Hip and knee muscle torque and its relationship with
dynamic balance in chronic ankle instability, copers and controls. J Sci Med Sport.
2021;24(7):647-652. doi:10.1016/j.jsams.2021.01.009

27. Chu ECP, Chin WL, Bhaumik A. Cervicogenic dizziness. Oxf Med Case Reports.
2019;2019(11):476-478. Published 2019 Dec 9. doi:10.1093/omcr/omz115

28. Minguez-Zuazo A, Grande-Alonso M, Saiz BM, La Touche R, Lara SL. Therapeutic

patient education and exercise therapy in patients with cervicogenic dizziness: a
prospective case series clinical study. J Exerc Rehabil. 2016;12(3):216-225. Published
2016 Jun 30. doi:10.12965/jer.1632564.282

29. Murphy JR, Di Santo MC, Alkanani T, Behm DG. Aerobic activity before and following
short-duration static stretching improves range of motion and performance vs. a traditional
warm-up. Appl Physiol Nutr Metab. 2010;35(5):679-690. doi:10.1139/H10-062

30. Bishop D. Warm up II: performance changes following active warm up and how to structure
the warm up. Sports Med. 2003;33(7):483-498. doi:10.2165/00007256-200333070-00002

31. Jacobson BH, Thompson B, Wallace T, Brown L, Rial C. Independent static balance training
contributes to increased stability and functional capacity in community-dwelling elderly
people: a randomized controlled trial. Clin Rehabil. 2011;25(6):549-556.
doi:10.1177/0269215510392390

32. Lai C, Tseng S, Huang C, et al. Fun and accurate static balance training to enhance fall
prevention ability of aged adults: A preliminary study. Human Factors and Ergonomics in
Manufacturing & Service Industries. 2012;23(6):517-527. doi:10.1002/hfm.20345

33. Lesinski M, Hortobágyi T, Muehlbauer T, Gollhofer A, Granacher U. Effects of Balance

Training on Balance Performance in Healthy Older Adults: A Systematic Review and Meta-
analysis [published correction appears in Sports Med. 2016 Mar;46(3):457]. Sports Med.
2015;45(12):1721-1738. doi:10.1007/s40279-015-0375-y

33
34. Mansfield A, Wong JS, Bryce J, Knorr S, Patterson KK. Does perturbation-based balance
training prevent falls? Systematic review and meta-analysis of preliminary randomized
controlled trials. Phys Ther. 2015;95(5):700-709. doi:10.2522/ptj.20140090

35. Okubo Y, Schoene D, Lord SR. Step training improves reaction time, gait and balance and
reduces falls in older people: a systematic review and meta-analysis. Br J Sports Med.
2017;51(7):586-593. doi:10.1136/bjsports-2015-095452

36. Geohagen O, Hamer L, Lowton A, et al. The effectiveness of rehabilitation interventions

including outdoor mobility on older adults' physical activity, endurance, outdoor mobility
and falls-related self-efficacy: systematic review and meta-analysis. Age Ageing.
2022;51(6):afac120. doi:10.1093/ageing/afac120

37. Kyrdalen IL, Thingstad P, Sandvik L, Ormstad H. Associations between gait speed and well-
known fall risk factors among community-dwelling older adults. Physiother Res Int.
2019;24(1):e1743. doi:10.1002/pri.1743

38. Sung YH. Suboccipital Muscles, Forward Head Posture, and Cervicogenic
Dizziness. Medicina (Kaunas). 2022;58(12):1791.

39. Reid SA, Callister R, Snodgrass SJ, Katekar MG, Rivett DA. Manual therapy for
cervicogenic dizziness: Long-term outcomes of a randomised trial. Man Ther.
2015;20(1):148-156. doi:10.1016/j.math.2014.08.003

40. Yaseen K, Hendrick P, Ismail A, Felemban M, Alshehri MA. The effectiveness of manual
therapy in treating cervicogenic dizziness: a systematic review. J Phys Ther Sci.
2018;30(1):96-102. doi:10.1589/jpts.30.96

41. Baker SM, Marshak HH, Rice GT, Zimmerman GJ. Patient participation in physical therapy
goal setting. Phys Ther. 2001;81(5):1118-1126.

34
Table 1.

Patient Medications
Medication Dosage

hydrocortisone One dose daily

vitamin D 600 IU daily

omeprazole 20 mg daily

alendronate 5 mg daily
Table 2.

Manual Muscle Test Grading Scale8

Number Grade Definition

0 No evidence of contraction by vision or
palpation
1 Slight contraction
2- Movement through partial test range in
gravity-eliminated position
2 Movement through complete test range
in gravity-eliminated position
2+ Movement through complete test range
in gravity-eliminated position and
through up to one-half of test range
against gravity
3- Movement through complete test range
in gravity-eliminated position and
through more than one half of test range
against gravity
3 Movement through complete test range
against gravity
3+ Movement through complete test range
against gravity and able to hold against
minimum resistance
4 Movement through complete test range
against gravity and able to hold against
moderate resistance
5 Movement through complete test range
against gravity and able to hold against
maximum resistance
Table 3.

Manual Muscle Testing Lower Extremity

Movement Tested Initial Initial Discharge: Discharge:

Examination: Examination: Left Strength Right Strength
Left Strength Right Strength Grade Grade
Grade Grade
Hip Flexion 3+/5 4/5 4/5 5/5

Hip Extension 3+/5 3+/5 4/5 4/5

Hip Abduction 3+/5 3+/5 5/5 5/5

Hip Adduction 4/5 4/5 5/5 5/5

Hip Internal Rotation 4/5 5/5 5/5 5/5

Hip External Rotation 3+/5 4/5 4/5 4/5

Knee Flexion 3+/5 4/5 5/5 5/5

Knee Extension 4/5 4/5 5/5 5/5

Ankle Dorsiflexion 4/5 4/5 5/5 5/5

Ankle Plantarflexion 3+/5 3+/5 4/5 4/5

Ankle Inversion 4/5 4/5 4/5 4/5

Ankle Eversion 4/5 4/5 4/5 4/5

a
3/5 = Movement through complete test range against gravity. 3+/5 = Movement through
complete test range against gravity and able to hold against minimum resistance. 4/5 =
Movement through complete test range against gravity and able to hold against moderate
resistance. 5/5 = Movement through complete test range against gravity and able to hold against
maximum resistance.

Table 4.
The Activities-specific Balance Confidence (ABC) Scale10

Activity Patient-Reported Patient-Reported

How confident are you that you Confidence at Evaluation Confidence at Discharge
will not lose your balance or (0-100%) (0-100%)
become unsteady when you…
Walk around the house? 70% 80%
Walk up or down stairs? 40% 60%
Bend over and pick up a slipper 70% 70%
from the front of a closet door?
Reach for a small can off a 70% 80%
shelf at eye level?
Stand on your tip toes and 70% 80%
reach for something above your
head?
Stand on a chair and reach for 0% 30%
something?
Sweep the floor? 70% 90%
Walk outside the house to a car 60% 80%
parked in the driveway?
Get into or out of a car? 70% 80%
Walk across a parking lot to the 40% 60%
mall?
Walk up or down a ramp? 50% 60%
Walk in a crowded mall where 40% 60%
people rapidly walk past you?
Are bumped into by people as 40% 60%
you walk through the mall?
Step onto or off an escalator 50% 70%
while you are holding onto a
railing?
Step onto or off an escalator 0% 30%
while holding onto parcels such
that you cannot hold onto the
railing?
Walk outside on icy sidewalks? 0% 40%
Total ABC Score: 740 1030
Confidence: 740/16 = 46.3% of self 1030/16 = 64.4% of self
confidence confidence

Table 5.
The Dizziness Handicap Inventory (DHI)14

Question (P=physical,
Evaluation Discharge
E=emotional, F=functional)
P1. Does looking up increase
Sometimes (2) Sometimes (2)
your problem?
E2. Because of your problem,
Sometimes (2) Sometimes (2)
do you feel frustrated?
F3. Because of your problem,
do you restrict your travel for No (0) No (0)
business or recreation?
P4. Does walking down the
aisle of a supermarket increase No (0) No (0)
your problems?
F5. Because of your problem,
do you have difficulty getting No (0) No (0)
into or out of bed?
F6. Does your problem
significantly restrict your
participation in social activities,
Sometimes (2) No (0)
such as going out to dinner,
going to the movies, dancing,
or going to parties?
F7. Because of your problem,
No (0) No (0)
do you have difficulty reading?
P8. Does performing more
ambitious activities such as
sports, dancing, household
Yes (4) No (0)
chores (sweeping or putting
dishes away) increase your
problems?
E9. Because of your problem,
are you afraid to leave your
home without having without No (0) No (0)
having someone accompany
you?
E10. Because of your problem
have you been embarrassed in No (0) No (0)
front of others?
P11. Do quick movements of
your head increase your Sometimes (2) Sometimes (2)
problem?
F12. Because of your problem,
Yes (4) No (0)
do you avoid heights?
P13. Does turning over in bed
No (0) No (0)
increase your problem?
 F14. Because of your problem,
is it difficult for you to do
Sometimes (2) Sometimes (2)
strenuous homework or yard
work?
E15. Because of your problem,
are you afraid people may think Sometimes (2) No (0)
you are intoxicated?
F16. Because of your problem,
is it difficult for you to go for a Yes (4) Sometimes (2)
walk by yourself?
P17. Does walking down a
sidewalk increase your Sometimes (2) Sometimes (2)
problem?
E18. Because of your problem,
is it difficult for you to No (0) No (0)
concentrate?
F19. Because of your problem,
is it difficult for you to walk No (0) No (0)
around your house in the dark?
E20. Because of your problem,
are you afraid to stay home No (0) No (0)
alone?
E21. Because of your problem,
No (0) No (0)
do you feel handicapped?
E22. Has the problem placed
stress on your relationships
No (0) No (0)
with members of your family or
friends?
E23. Because of your problem,
No (0) No (0)
are you depressed?
F24. Does your problem
interfere with your job or No (0) No (0)
household responsibilities?
P25. Does bending over
Sometimes (2) Sometimes (2)
increase your problem?
Total Score 28 (mild handicap) 14 (no handicap)
a
Yes = 4 points. Sometimes = 2 points. No = 0 points
b
16-34 points (mild handicap). 36-52 points (moderate handicap). 54+ points (severe handicap)

Table 6.
Berg Balance Test (BBS)16

Task Evaluation Discharge Scoring

4 = able to stand without using hands and stabilize
independently
3 = able to stand independently using hands
Sitting to Standing 4 4 2 = able to stand using hands after several tries
1 = needs minimal aid to stand or stabilize
0 = needs moderate or maximal aid to stand
4 = able to stand safely for 2 minutes
3 = able to stand 2 minutes with supervision
2 = able to stand 30 seconds unsupported
Standing unsupported 4 4 1 = needs several tries to stand 30 seconds
unsupported
0 = unable to stand 30 seconds unsupported
4 = able to sit safely and securely for 2 minutes
3 = able to sit 2 minutes under supervision
Sitting unsupported,
4 4 2 = able to sit for 30 seconds
feet on floor 1 = able to sit 10 seconds
0 = unable to sit without support for 10 seconds
4 = sits safely with minimal use of hands
3 = controls descent by use of hands
2 = uses back of legs against chair to control
Standing to sitting 4 4 descent
1 = sits independently but has uncontrolled
descent
0 = needs assist to sit
4 = able to transfer safely with minor use of hands
3 = able to transfer safely with definite use of
hands
Transfers 3 4 2 = able to transfer with verbal cueing and/or
supervision
1 = needs one person assist
0 = needs two people to assist
4 = able to stand 10 seconds safely
3 = able to stand 10 seconds with supervision
2 = able to stand 3 seconds
Standing unsupported
3 4 1 = unable to keep eyes closed 3 seconds but
with eyes closed stands safely
0 = needs help to attain position and unable to
hold 15 seconds
4 = able to place feet together and stand 1 minute
safely
3 = able to place feet together and stand 1 minute
with supervision
Standing unsupported 2 = Able to place feet together independently but
3 3 unable to hold for 30 seconds
with feet together
1 = needs help to attain position but able to stand
15 seconds with feet together
0 = needs help to attain position and unable to
hold for 15 seconds.
Reaching forward with 2 3 4 = can reach forward confidently 25 cm
outstretched arm 3 = can reach forward 12 cm
2 = can reach forward 5 cm
 1 = reaches forward but needs supervision
0 = loses balance while trying/needs support
4 = able to pick up object safely and easily
3 = able to pick up object but needs supervision
Pick up object from the 2 = unable to pick up but reaches 2-5 cm from
3 4 object and keeps balance independently
floor
1 = unable to pick up object and needs supervision
0 = unable to try/needs assist from falling
4 = looks behind from both sides and weight shifts
well
3 = looks behind one side only and other side
Turning to look behind shows less weight shift
2 4 2 = turns sideways only but maintains balance
left and right shoulder
1 = needs supervision when turning
0 = needs assist to keep from losing balance or
falling
4 = able to turn 360 degrees safely in 4 seconds or
less
3 = able to turn 360 degrees safely to one side in 4
Turing 360 degrees 2 3 seconds or less
2 = able to turn 360 degrees safely but slowly
1 = needs close supervision or verbal cueing
0 = needs assistance while turning
4 = able to stand safely and able to complete 8
steps in <20 seconds
Dynamic weight 3 = able to stand safely and complete 8 steps in
>20 seconds
shifting while standing 4 4 2 = able to complete 8 steps with supervision
unsupported 1 = able to complete >2 steps and needs minimal
assist
0 = needs assistance to keep from falling
4 = able to place feet tandem unsupported and
stand for 30 seconds
3 = able to place foot ahead independently and
Standing unsupported, stand for 30 seconds
3 4 2 = able to take a small step independently and
one foot in front
hold 30 seconds
1 = needs help to step but can hold 15 seconds
0 = loses balance while stepping or standing
4 = able to lift leg independently and hold >10
seconds
3 = able to lift leg independently and hold 5-10
seconds
Standing on one leg 2 3 2 = able to lift leg independently and hold >3
seconds
1 = tries to lift leg and unable to hold >3 seconds
0 = unable to try or needs assist to avoid fall
Total Score: 43/56 52/56

Table 7.
Interventions per Session

Interventions Week
Week 1 Week 2 Week 3 Week 4 Week 5
Therapeutic Straight leg hip Session 1: x Session 1: x Session 1: x Session 1: x Session 1: x
Exercise flex/abd/add/ex Session 2: x Session 2: x Session 2: Session 2: x Session 2:
t (progressed Session 3: x Session 3: x Session 3: x Session 3: x Session 3: x
with resistance
bands)
Supine bridges Session 1: x Session 1: Session 1: Session 1: Session 1:
Session 2: x Session 2: Session 2: Session 2: Session 2:
Session 3: x Session 3: Session 3: Session 3: Session 3:
Supine straight Session 1: x Session 1: Session 1: Session 1: Session 1:
Leg Raises Session 2: x Session 2: Session 2: Session 2: Session 2:
Session 3: x Session 3: Session 3: Session 3: Session 3:
Heel raises Session 1: Session 1: x Session 1: x Session 1: x Session 1: x
(progressed by Session 2: x Session 2: Session 2: x Session 2: x Session 2: x
performing in Session 3: x Session 3: x Session 3: x Session 3: x Session 3: x
staggered
stance with
added head
turns)
Cervical muscle Session 1: x Session 1: x Session 1: x Session 1: x Session 1:
stretches Session 2: x Session 2: x Session 2: x Session 2: Session 2: x
Session 3: x Session 3: x Session 3: x Session 3: x Session 3:
Cervical Session 1: x Session 1: x Session 1: x Session 1: x Session 1:
retractions Session 2: x Session 2: x Session 2: x Session 2: Session 2:
Session 3: x Session 3: x Session 3: x Session 3: x Session 3:
Single leg Session 1: Session 1: x Session 1: Session 1: Session 1:
forward trunk Session 2: Session 2: Session 2: Session 2: Session 2:
lean squats Session 3: x Session 3: Session 3: Session 3: Session 3: x
Recumbent Session 1: x Session 1: x Session 1: x Session 1: x Session 1:
bicycle Session 2: x Session 2: x Session 2: x Session 2: x Session 2:
Session 3: x Session 3: x Session 3: x Session 3: x Session 3:
Resistance band Session 1: Session 1: x Session 1: x Session 1: Session 1:
side lying hip Session 2: Session 2: x Session 2: Session 2: Session 2:
abduction Session 3: x Session 3: Session 3: Session 3: Session 3:
Forward/lateral Session 1: Session 1: Session 1: x Session 1: x Session 1: x
lunges onto Session 2: Session 2: x Session 2: x Session 2: Session 2:
angled mini Session 3: Session 3: Session 3: Session 3: Session 3: x
trampoline
4-inch step Session 1: Session 1: Session 1: x Session 1: Session 1: x
up/over Session 2: Session 2: Session 2: x Session 2: x Session 2: x
Session 3: Session 3: Session 3: Session 3: x Session 3: x
Weighted ball Session 1: Session 1: Session 1: x Session 1: Session 1: x
squat with UE Session 2: Session 2: Session 2: Session 2: x Session 2:
diagonals Session 3: Session 3: Session 3: Session 3: x Session 3: x
Balance Week 1 Week 2 Week 3 Week 4
Training Hip extension Session 1: x Session 1: x Session 1: x Session 1: x Session 1: x
with backward Session 2: x Session 2: x Session 2: x Session 2: x Session 2: x
walking and Session 3: x Session 3: x Session 3: x Session 3: x Session 3: x
head turns
Blue half-ball Session 1: x Session 1: x Session 1: Session 1: x Session 1:
lunge loading Session 2: x Session 2: x Session 2: Session 2: Session 2:
(progressed by Session 3: x Session 3: x Session 3: x Session 3: Session 3:
performing step
ups to single-
leg stance)
Wobble board Session 1: Session 1: x Session 1: x Session 1: Session 1: x
balance Session 2: x Session 2: x Session 2: x Session 2: Session 2:
Session 3: x Session 3: x Session 3: Session 3: Session 3: x
Cone reaching Session 1: Session 1: x Session 1: x Session 1: x Session 1: x
while standing Session 2: Session 2: Session 2: x Session 2: x Session 2: x
on foam pad Session 3: x Session 3: x Session 3: x Session 3: Session 3:
(progressed by
increasing
speed of turns)
Foam pad Session 1: Session 1: Session 1: x Session 1: Session 1:
standing Session 2: Session 2: x Session 2: Session 2: Session 2:
playing catch Session 3: Session 3: Session 3: x Session 3: x Session 3:
with ball
(progressed by
throwing ball
quickly and
outside base of
support)
Foam pad Session 1: Session 1: Session 1: x Session 1: x Session 1:
tandem stance Session 2: x Session 2: Session 2: Session 2: Session 2:
(progressed to Session 3: Session 3: x Session 3: Session 3: Session 3:
eyes closed)
Single leg Session 1: Session 1: x Session 1: x Session 1: x Session 1:
stance Session 2: x Session 2: Session 2: Session 2: Session 2:
(progressed to Session 3: Session 3: Session 3: Session 3: Session 3:
eyes closed
with external
perturbation)
Tandem stance Session 1: Session 1: Session 1: Session 1: x Session 1: x
with resistance Session 2: Session 2: Session 2: Session 2: x Session 2:
from band Session 3: Session 3: Session 3: Session 3: x Session 3:
(progressed by
increasing band
strength)
Single leg Session 1: Session 1: x Session 1: x Session 1: x Session 1:
forward trunk Session 2: Session 2: Session 2: Session 2: Session 2:
Session 3: x Session 3: Session 3: Session 3: x Session 3: x
 flexion to pick
up object off
floor
Tandem stance Session 1: Session 1: Session 1: Session 1: Session 1:
trampoline ball Session 2: Session 2: Session 2: Session 2: Session 2: x
toss Session 3: Session 3: Session 3: Session 3: Session 3: x
Gait Week 1 Week 2 Week 3 Week 4
Training Hurdle up and Session 1: x Session 1: x Session 1: x Session 1: Session 1:
over forward, Session 2: x Session 2: Session 2: x Session 2: x Session 2: x
backward, Session 3: x Session 3: x Session 3: Session 3: x Session 3:
lateral
(progressed by
adding 90
degree turns
Obstacle course Session 1: Session 1: Session 1: Session 1: x Session 1: x
including Session 2: Session 2: x Session 2: x Session 2: x Session 2: x
hurdles, steps, Session 3: Session 3: x Session 3: Session 3: Session 3: x
agility ladder,
cones
(progressed by
adding head
turns and
external
perturbation)
Outdoor gait Session 1: Session 1: Session 1: Session 1: Session 1:
training Session 2: Session 2: x Session 2: Session 2: Session 2: x
Session 3: x Session 3: Session 3: x Session 3: x Session 3:
Tandem line Session 1: Session 1: Session 1: Session 1: x Session 1:
walking with Session 2: Session 2: Session 2: x Session 2: x Session 2: x
hurdles Session 3: Session 3: x Session 3: Session 3: Session 3: x
Backward Session 1: Session 1: Session 1: Session 1: Session 1:
Walking Session 2: Session 2: Session 2: Session 2: Session 2:
Session 3: Session 3: Session 3: Session 3: Session 3:
Manual Session 1:
Therapy Session 2:
Session 3:
Soft tissue Session 1: x Session 1: x Session 1: Session 1: Session 1:
mobilization Session 2: Session 2: x Session 2: Session 2: Session 2:
Session 3: x Session 3: x Session 3: Session 3: Session 3:
Suboccipital Session 1: x Session 1: x Session 1: Session 1: Session 1:
release Session 2: Session 2: x Session 2: Session 2: Session 2:
Session 3: x Session 3: x Session 3: Session 3: Session 3:
 % Balance Confidence
Discharge Evaluation

64%

46%

Figure 1.
ABC Scores at evaluation and discharge. A significant change in balance confidence has been
deemed to be a change of 11.28%
 Timed Up and Go
17
16
15
14
13
12
11
10 Patient Score
Seconds

9 Increased Fall Risk

8 15.8 12 12.3 12
7
6
5
4
3
2
1
0
Evaluation Discharge

Figure 2.
Timed Up and Go (TUG) scores at evaluation and discharge compared to the score in which a
patient is considered to be at an increased fall risk. A significant change in TUG score has been
determined to be 3.2 seconds.