Tinetti and Otago Programs

EXP 590
August 12, 2015
Caitlin Benbow

Purpose
The purpose of my project is to create balance exercises for the cardiac and pulmonary
patients at Gundersen Health Systems. The balance exercises will be created based on the
Otago Balance Exercise program. The other half of my project is creating a score sheet,
demonstrating, and providing an explanation to the exercise physiology team about Tinetti
Balance Assessment. The programs at Gundersen, in the exercise physiology department, are
lacking a reliable and valid balance assessment tool to assess their patients for fall risk. Seeing
the need for a proper balance assessment is why I chose to do this project. The benefits to the
patients will be great because they will be properly screened and high fall risk patients will be
able to perform balance training to improve their stratification.
Rationale
Improving patients fall risk stratification is the reason a proper assessment and program
needs to be implemented in the department. The exercise physiology department deals with
numerous frail patients because of heart or respiratory failure. These patients need proper
screening to ensure the safety of the patient during rehab.
The motivation for this project came from observing cardiac and pulmonary patients
struggle with walking, stationary balance, and balance recovery. In the initial appointments, a
very minimalistic assessment is done to assess fall risk for each individual patient. However, the
current assessment does not allow the exercise physiologist to accurately assess the patients
balance, both stationary and ambulatory. This can lead to improper exclusion for a fall risk
classification; which can be potentially harmful to patients.
As people age, the likelihood to suffer from a fall increases. Falls can result in injury,
necessary lifestyle changes, increased healthcare expenses, and possibly death. Studies have
shown that 33% of elderly, 65 years of age or older, fall at least once per year (Vaught, Soriano).
Patients who are in a nursing home or participating in any sort of rehabilitation have a greater
percentage of falls. Approximately 50% of these patients fall at least once per year (Vaught).
Many falls happen because of multiple factors, and most often elderly patients do not know the
risk factors associated with falls. When elderly patients fall it is often due to environmental
hazards or because physical demands outweigh the patients ability to maintain postural
stability. Postural stability depends on the functioning of sensory, central integrative, and
musculoskeletal effector components. As people age, the systems go through physiologic
changes which can ultimately lead to falls in the elderly (Soriano). Some of the physiologic
changes include declines in proprioception, visual acuity, joint mobility, and judgment/decision
making along with the increase in likelihood of having orthostatic hypotension. Gait changes,
such as smaller steps, slower gait, decreased ability to counterbalance, and wider stance play a
role in the increased fall risk (Vaught).
There are predisposing risk factors that contribute to the increased fall risk in elderly and
rehabilitation patients. Predisposing risk factors include: sensory, central nervous system,
musculoskeletal, medications, and postural hypotension. Of the sensory systems, visual acuity,
contrast sensitivity, and depth perception are the most relevant to avoiding a fall and
maintaining postural stability. Patients who wear bifocal glasses have a greater risk of falling if
they were to disrupt their postural stability because the person is unable to focus on their feet
and the ground to regain stability because they would be looking through the reading portion of
the bifocals. Hearing allows individuals to orient themselves in space. However, 50% of elderly
have hearing loss of varying degrees. The vestibular and proprioception systems are what
assist individuals with spatial orientation while sitting and during ambulatory activities.
Proprioception is recruited more heavily during ambulation on uneven surfaces or when other
sensory systems are impaired.

The central nervous system is intricately connected to other systems necessary for
balance. When patients have disorders or disease affecting the CNS this can predispose an
elderly patient to falls. Diseases that have physical or cognitive impairments increase the risk of
falling the greatest for those patients. Examples of this would be Parkinsons disease, stroke,
Alzheimers, and dementia (Salzman, Soriano).
Impairment to the musculoskeletal system affects stability. Arthritis is common in the
elderly, and having arthritis increases the risk of falls through pain, muscle weakness, or
decreased proprioception. In addition, especially with diabetic patients, feet abnormalities also
affect fall risk because of altered gait pattern. Postural hypotension can lead to falls because of
a compromise in cerebral blood flow (Vaught, Soriano).
Effects of medication on fall risk has been studied for a number of years. Medications
that can affect balance include: sedatives, hypnotics, antidepressants, anxiolytics, digoxin, and
diuretics. When four or more medications are combined, studies have shown that those patients
have the greatest risk of falling. Combining alcohol with mediation increases the likelihood of
falls because of dehydration, fatigue, electrolyte imbalances, and cognitive impairment (Ray,
Cumming, Soriano). These are all various explanations as to why a valid and reliable balance
assessment protocol needs to be utilized in this department. Research has shown that a proper
program can help improve balance in the population of patients that the exercise physiology
department works with on a daily basis.
Clinical Evidence in Cardiopulmonary Patients
Lung impairment is the most recognized symptom of chronic obstructive lung disease
(COPD). However, there are other systemic effects caused by the oxidative stress and
inflammation of COPD that can contribute to balance impairments (Marques). Skeletal muscle
has alterations in fiber and muscle mass, capillarization of blood vessels to the muscles,
abnormal electrical activity which causes a reduction in signal conduction speed, and peripheral
neuropathy. Approximately 28-87% of patients with COPD have some degree of
neurophysiological alterations (Nantsupawat). These alterations ultimately affect the patients
gait and gait speed which leads to more frequent falls and increased time spent in double
support or bilateral stance when walking (Nantsupawat). Patients who have a greater severity of
hypoxemia are seen with greater neurophysiological alterations (Kayacan). This can include
reductions in nerve conduction speed and range of the action potential signal. Functional
alterations are typically assessed by performing a 6 minute walk test (6MWT) and Tinetti
Balance Assessment. Somatosensorial and vestibular systems typically decline as people age.
These changes along with a COPD diagnosis make elderly patients more susceptible to
balance alterations which predisposes these patients to falls. ACSM recommends a balance
assessment and treatment plan for patients with COPD because balance and coordination are
imperative elements in activities of daily living (ADLs) and a patients quality of life (QOL)
(Rocco).
COPD patients who are oxygen-dependent have lower scores in balance, mobility, and
coordination when compared to COPD patients who are not oxygen-dependent (Butcher).
COPD patients show a slowing of monosynaptic reflexes and functional alterations which can
lead to a worse prognosis for falls compared to age matched healthy individuals (Rocco). These
slowed reflexes are what impairs COPD patients to recover their balance if perturbed
(Beauchamp). To fully assess balance in COPD patients a separate static balance test can be
used which is performed on a force plate in addition to the Tinetti Balance Assessment. The
patient would stand erect for 60 seconds on the force plate while it analyzes the center of
pressure. Studies have shown that COPD patients have worse results in speed of patellar and
Achilles nerve conductions, peripheral muscle strength, and overall Tinetti score compared to
healthy individuals (Marques). Although conduction pathways are typically damaged

permanently, pulmonary rehabilitation with incorporation of balance training has been shown to
improve Get Up and Go scores, as well as the patients overall Tinetti Balance score. Patients
notice an improvement in their functional balance as a result of participating in pulmonary
rehabilitation that incorporates exercise with balance training (Beauchamp, Marques).
The effects of balance training during pulmonary rehabilitation sessions is relatively safe.
A study conducted by Beauchamp in COPD patients, with age range between 62.5 and 76.6,
reported no adverse events from balance training sessions. This demonstrates that
incorporating balance training with elderly patients is safe and beneficial for the patients.
Balance training improves primary measures of balance and fall risk in patients with COPD.
Tinetti Balance scores improved between 3.5-5.4 points from baseline assessment.
Improvements from balance training are observed with the patients biomechanics and gait,
reaction time, and sensory output (Nantsupawat). Furthermore, using the Activities-Specific
Balance Confidence (ABC) scale, COPD subjects had a 13 point improvement in their balance
confidence compared to baseline measurements (Beauchamp).
Outpatient cardiac rehabilitation programs have been associated with significant benefits
when patients participate at least three months in the program. Regular adherence to cardiac
rehabilitation schedule and exercise has favorable effects on body composition, lipoprotein
analysis, a reduction in cardiovascular risk factors, and an increase in exercise capacity.
Benefits and continuation of exercise has increased benefits in patients who maintain exercise
and rehabilitation sessions for greater than six months to one year. Patients are the most
successful when upon graduation from phase II cardiac rehabilitation join a phase III program.
Phase III programs help hold patients accountable for their progress and helps instill in them the
importance of daily exercise and how to make exercise a priority. The increased compliance in
cardiac rehabilitation patients who join a phase III program can be attributed to social
interactions, peer support, and structured supervision. Long term maintenance programs that
include exercise and balance components are shown to slow down the decline in exercise
capacity and prolong independent living and quality of life (Mandic).
The typical phase III, maintenance, program consists of two-three 60 minute group
exercise sessions per week. Exercise sessions for maintenance programs should include
aerobic, strength, flexibility, and balance/coordination training. There are many different forms of
balance training available. However, one of the more popular trainings supported by the
literature is the Otago Balance Exercises. Before beginning balance training with patients a
comprehensive clinical assessment of their current stage of balance is important for diagnostic
and therapeutic purposes. A recommended screening tool would be Tinetti Balance Assessment
(Mancini). The Otago program consists of 12 various balance exercises ranging from static to
dynamic movements. Each exercise has a specific number of repetitions and sets to complete.
A detailed progression is also provided for each exercise (Mandic, Mancini).
In follow-up assessments with patients who attended a maintenance program for greater
than one year the following trends were seen: increase in lower body strength, decrease in
upper body strength, and an increase in body weight and body fat. Aging is positively correlated
with the increases in body weight and fat seen in the follow-up assessment. Sarcopenia and
deconditioning leads to atrophy of upper body musculature. Incorporating strength training
exercises, especially upper body, is important for cardiac rehabilitation patients to help them
maintain their independence (Mandic). However, when maintenance program patients were
compared to patients who did not continue with a structured exercise program there were
smaller increases in body weight and a decrease in body fat percentage. When comparing
patients who participated in a three month or 12 month program and the corresponding increase
in exercise capacity; only 6% saw an increase in exercise capacity in the three month group,
whereas, the 12 month group saw a 44% increase in exercise capacity (Rogers, Mandic).

For patients to adhere to exercise and part of their daily routine it can take up to one and
a half years. Structured programs are associated with a higher likelihood of regular physical
activity post cardiac rehabilitation graduation. In order to slow the progression of coronary artery
stenosis a minimal energy expenditure of 1,800 calories per week needs to be met. 55.9% of
post graduate cardiac rehabilitation patients meet this minimum recommendation. Likewise,
patients who participate in cardiac rehabilitation have a better long term survival than patients
who declined cardiac rehabilitation (Mandic).
Long term phase III programs, which incorporate exercise and balance, play a crucial
role in maintaining or slowing the decline of exercise capacity in elderly coronary artery disease
patients. Maintaining exercise capacity allows patients to prolong their current level of physical
functioning to maintain independent living.
Tinetti and Otago Descriptions
The goal of cardiac and pulmonary rehabilitation is for patients to regain their
independence and confidence that they had before the onset of their medical issue. Regaining
independence and confidence for patients involves aerobic and resistance training, balance
training, and patient education. Initial balance assessments are a crucial piece in helping a
patient regain their independence. By assessing balance initially, this allows exercise
physiologists to better progress their patients during balance training and tailor balance training
to the patients specific needs. The balance assessment that is being incorporated into the
cardiac and pulmonary rehabilitation regimen is the Tinetti Balance Assessment and Otago
Balance Training.
The Tinetti Balance Assessment allows the exercise physiologist to quantify the patients
balance score. This assessment looks at a patients overall balance and stability through a
series of stationary and ambulatory assessments. The assessment looks at the body as a whole
and how certain areas are effected by poor balance. Postural changes are assessed sitting and
standing, postural sway and counterbalance is assessed when the patient moves from sitting to
standing, as well as when in a unipedal stance. Each assessment is scored with a point value,
which allows for an objective assessment. An objective assessment allows the staff to pinpoint
what aspects of a patients balance or stability needs to be addressed first through balance
training. Numerical values allows progress to be easily tracked compared to subjective notes
which is currently being used in their balance assessment at Gundersen.
The Otago Balance Training can be introduced during cardiac or pulmonary
rehabilitation and continued at home when the patient graduates from their respective program.
Otago Balance Training compliments the Tinetti Balance Assessment. The Otago program
combines stationary and ambulatory balance exercises to help the patient improve necessary
areas. The goal of the balance program is to accumulate time or steps, based off of what
exercise is being done. The program also instills confidence in the patient that they can improve
their balance and be safe doing activities of daily living.
The proposed outcome from the Otago Balance Training program is to reduce the
likelihood of falls in the patients by improving their stability and balance recovery. Research has
shown that participation in a balance training program reduces the fall rate approximately 35%
(Campbell, Liu-Ambrose). Research has also shown that patients who participate in a phase II
program, which consists of exercise and balance training, and then continue to participate in a
phase III program have greater improvements than patients who just complete phase II.
Procedures
The Tinetti Balance Assessment should be conducted during each initial appointment,
for cardiac and pulmonary patients. This assessment will accurately screen each patient, based

off of individual ability, for a fall risk. It will be up to the exercise physiologist to make a clinical
decision on whether the patient is assessed for balance and gait, or just one aspect. If the
patient needs an assistive device to ambulate then the exercise physiologist can decide to just
assess the balance protocol. From the initial assessment and fall risk classification, the patient
will then receive a tailored balance training protocol, based on the Otago Balance Training
program. The exercise physiologist would demonstrate the desired exercises for the patient to
complete and then provide the patient with a balance exercise handout and an associated grid
sheet. Balance training should be done 2-3 days per week. In order for the assessment and
balance training program to be valid and reliable, staff need to be familiar with each protocol.
Watching training videos, having sporadic competency checks, and following the outlined
protocols listed below are all steps to help ensure that the technician is being as accurate as
possible.
Tinetti and Otago Protocols
Assessing the risk of falls can be difficult to determine, especially in the elderly
population. The Tinetti Balance Assessment is a widely used protocol to assess a patients fall
risk because it assesses the patients risk profile for ground level falls, involves simple physical
tests that can be done without the need of a health care professional, and assesses a variety of
different movements that a patient would do on a daily basis (Pape). The Tinetti assessment has
two parts, the first part is balance and the second part is a gait analysis. The balance section is
scored out of 16 points. The balance section is composed of nine different aspects of balance.
The first aspect that is observed by the technician is the patients sitting balance. This is going to
include how much support is needed for the patient to sit in a chair and how much the patient
needs assistance when rising from a chair. The next aspect is the patients immediate standing
balance. This is assessed in the first five seconds of standing. Observations are made on how
unsteady the patient was, how much trunk sway, did the patient shuffle their feet, and was an
assistive device used to help the patient rise. Next the patients stationary standing balance is
observed. The technician is looking for how wide the patients stance is and whether or not they
appear steady on their feet. The next three aspects of balance involve changing proprioception.
First the patient is gently nudged in the sternum, then eyes closed, and lastly 360 turn with eyes
open. The technician is looking for trunk sway, shuffle steps, discontinuous steps, and excessive
arm movement. Lastly, the patient is asked to return to their seat. This is to assess the safety to
which a patient sits down and whether or not they use assistance.
The gait analysis section is scored out of 12 points. This section consists of eight
assessments. The patient is asked to walk at a normal pace and the technician assesses the
patients initial movement to gait, step length, height, symmetry, and continuity, foot clearance,
any noticeable marked deviation from a straight line, and any extraneous body movement. Any
abnormalities from right to left side would also increase the likelihood of a fall.
A score less than or equal to 18 signifies that the patient is at a fivefold increase for
falling (Vaught). This patient would be classified as a high fall risk. A patient who scores between
19-23 would be a moderate fall risk. And a patient who scores greater than or equal to 24 is
deemed a low fall risk. Fall risk classification is based off of both the balance and gait sections.
The Otago Balance Training program is designed to focus on muscle strengthening as
well as balance-retraining. Muscle strengthening follows exercise recommendations. The
program is set up to be done two days/week. The program includes upper and lower body
exercises. However, more focus is on trunk and lower body strengthening. Exercises to
strengthen the patients core, quadriceps, hamstrings, hip flexors and extensors, calves, and
buttocks are included in the strengthening program. For our maintenance program patients, we
are having them follow the strength program already established. This strength program focuses

on all of those previously mentioned lower body areas, as well as upper body. The current
program focuses equally on upper and lower body; which the department feels is very important
for the population of patients that attend maintenance programs. Balance re-training is done
through dynamic balance exercises which challenges the patients proprioception and balance
recovery. The patients perform various unilateral and bilateral ambulatory exercises. The
program allows for progression to help the patient properly and safely progress and further
improve their balance. This program has been studied in the elderly population, specifically
ages 65-97 years old. The program has an overall fall reduction rate of 35%, with greater
reduction in fall risk observed in patients with a history of falls (Campbell, Liu-Ambrose). The
program helps patients improve their overall functional mobility and executive functioning. Part
of the executive functioning aspect is cognitive performance (Liu-Ambrose).
Equipment
The Tinetti and Otago protocols require very little equipment. The Tinetti protocol
requires a chair with arm rests and the Otago protocol requires a counter, table, or railing for
support. Both protocols require about a five square foot space to perform the assessment or
exercises in. Other than those two requirements for both protocols, the patient and exercise
physiologist do not need any additional equipment. This makes the Otago program very
accessible for all patients.
Supporting Research
Fall rates in the older population are 1.2 falls per person per year. In addition, falls occur
more frequently in women than men (Yoo). These can be caused by a random event. However,
the more likely cause would be deterioration and risk factors associated with falling. Initial
exercise for patients who are a fall risk should be under professional supervision and the
intensity and modality of exercise should be tailored to each patient. Exercise that was
performed three times per week under supervision and incorporated challenging balance
training was associated with a fall reduction rate as high as 60%. For higher fall risk populations,
exercises did not have as high of a reduction rate. The fall reduction rate in the high risk
population was approximately 18%. Exercise and fall risk reduction is generalizable to a larger
population. Tai chi and Otago exercise programs are two well-studied balance programs that
have been shown to reduce the risk of falls. These programs can be done in a group setting or
at home, and are associated with a 35% reduction in falls and related injuries from falls. Other
important factors to consider with exercise and improving balance is exercise duration, exercise
intensity, and exercise frequency. Studies have shown the best improvements with at least two
times per week of structured exercise and balance training for 20 weeks. However, at home
training needs to be done as well in order to see results and improvements in balance. An
interesting discovery from these studies is that exercise programs that incorporated walking into
the regimen were associated with a higher risk of falling. A possible explanation could be that
most falls happen when patients are walking. But an explanation supported by the literature is
that the more time spent walking in an exercise program the less time is spent on balance
training. These findings show that balance training is initially more important than walking. A
walking program is a great suggesting for at home exercise because walking will improve fitness
level, increase weight loss, and lower blood pressure. Reduced muscle strength is a risk factor
for falling. Strength training has been shown to have a positive effect on fall risk reduction. The
type of strength training recommended is low intensity, light load and higher repetitions, with a
Theraband (Yoo, Sherrington, Liu-Ambrose). This is recommended because moderate-high
intensity strength training can cause injury in the elderly population and no research shows
positive relationships between higher intensity training and reduced fall risk (Sherrington).

The recommended pieces of an exercise program to improve balance include: balance

exercise on firm and labile surfaces, resistance training, endurance training on a bike, and
flexibility to be able to maintain correct postural alignment. New treatments have incorporated
the augmented reality into training. This training involves additional information and a patients
personal purpose. The patient and professional will set up targets for the patient to strive to
achieve. This allows the patient to receive feedback, make changes, and envision the end goal
or reality. This type of training is similar to traditional methods except there is a greater patient
education aspect (Yoo, Campbell). Augmented training allows for virtual sessions that the
patient can do at their home. In addition, exercise for the patient can be pre-programmed. In a
way augmented training is like having a robot operated personal trainer. This training can
provide feedback, exercise changes virtually, create connections with other patients, and allow
for variation to prevent monotony (Yang).
For elderly patients the augmented training may not be appropriate. However, a study by
Campbell showed that four visits to the patients house over the first two months and then a
follow-up session at six months was associated with the greatest adherence and benefits. To
help patients keep up their motivation a phone or skype call was made every month to check in
and answer any questions the patient might have. The first initial visit was typically 60 minutes,
with the next three visits being 30 minutes each. To ensure safety for the patients, the exercise
program was individually tailored and each patient was given verbal and written instructions,
proper demonstrations, an illustration handout, and a workout video which provides cueing. The
phone calls and follow-up visit held patients accountable to their exercise program (Campbell).
The Otago exercise program specifically focuses on muscle strengthening, balance
training, and walks. Strengthening exercises are comprised of knee extension, knee flexion, hip
joint abduction, plantar flexion, and dorsiflexion. Balance training includes: backward walking,
walking and turning around, heel to toe walking, one leg stand, heel walking, toe walking, heel
to toe walking backwards, sit to stand, and stair walking. These exercises are performed three
times per week for 40-45 minutes. Patients who follow the Otago exercise program often notice
increased gait velocity (.80 m/s initially to 1.10 m/s), stride length, and cadence. The Otago
exercise program also shows improvement in static swaying while bilaterally standing and in the
Time Up and Go test. Overall balance also improved by assessing the patients four test
balance score. The four test balance score is when a patient stands with feet together, semi
tandem, tandem, and then on one leg. This quick assessment is used before starting the Otago
program to gauge at what level risk the patient is at in terms of overall balance, stability, and fall
risk. The Otago exercise program improves ambulatory posture which in turn helps the patient
stand more erect and regain balance a little quicker (Yoo, Campbell, Liu-Ambrose).
Walking and strength training are recommended for patients at a fall risk to help reduce
their risk and improve their overall health (Sherrington). However, the biggest factor on fall risks
is impaired balance. This is why the literature focuses on balance assessments and exercises
because this is the type of training that has been shown to improve overall fall risk.
Program Assessment and Analysis
To assess this program, it will initially be critiqued by the exercise physiology department
when I demonstrate and explain the purpose and research of the two protocols. If the team
decides the program is ready to be tested at this point, then the Tinetti protocol will be used in
initial appointments and the Otago balance exercises will initially just be used with Get Movin
patients. The team will ask for feedback from the Get Movin patients. And to assess changes in
balance and gait, the patients will have a pre and post Tinetti assessment.
After the department assessment, it was decided that the balance assessment be used
on the maintenance program patients and get feedback and comments from staff and patients
on the balance assessment.

Tinetti Balance Assessment Results

Tinetti Balance Assessment trials were completed after the department wide
presentation on the proposed changes to the balance assessment protocol and incorporation of
a balance exercise program. The Monday/Wednesday 3:00 pm and 4:00 pm maintenance
programs were selected to be participants to trial the balance assessment. These two classes
were picked because they have a diverse patient population and represented the targeted
cardiopulmonary patients the best since most of the maintenance program participants
previously attended cardiac or pulmonary rehab. The total patient representation between the
two classes was 13 patients, and five out of seven staff members were able to implement the
balance assessment at least once.
Feedback from the staff included: easy to administer, efficient assessment, subjective
scoring, and difficulty analyzing gait patterns. The biggest downfall with this assessment is
majority of the staff is not trained in gait analysis. This makes assessing the gain section of the
balance assessment more difficult, time consuming, and frustrating for the patient and staff. The
second negative with the assessment between staff is subjective scoring because every staff
member views a balance correction or postural sway differently. However, even with gait
analysis difficulties and variability in scoring, the assessment appeared efficient and easy to
administer.
Patient feedback included that the balance assessment was quick and focused on many
aspects of their daily activities and living. The most common feedback from patients was
confusion on why their gait was being analyzed when the assessment was focused on balance
and fall risk. The patients appeared to have more questions than the current fall risk
assessment format. However, the patients in the maintenance program said that they would
prefer the detailed assessment over the current method to classify fall risk.
Table 1. TBA Risk Classification
Low Risk
Moderate Risk
2
4

High Risk
7

TBA: Tinetti balance assessment

The Tinetti balance assessment identified five of the six patients previously classified as
high fall risks from the current assessment, as high fall risks based off of the Tinetti Balance
Assessment. The other patient was classified as a moderate fall risk according to the Tinetti
Balance Assessment. The Tinetti Balance Assessment classified two patients as high fall risks
that were not previously classified as such, three patients as moderate fall risks, and two
patients as low fall risks (Table 1). Variations in fall risk classifications are discussed below
along with reasons for the variation.
Discussion
The Tinetti Balance Assessment is widely used in occupational and physical therapy at
Gundersen. It is important to keep similarities between rehabilitation departments. This allows
for better interdisciplinary communication across departments and to patients doctors. The
balance assessment and program were initially brought to the attention of the exercise
physiology department by a physical therapist at Gundersen. Through courses at Carroll and lab
experiences I had more of a background in gait analysis and balance training than some of the
staff. I thought it would be interesting to do further research on the Tinetti Balance Assessment
and cardiopulmonary patients. Along with taking the research and implementing a balance
program. The original balance program was too advanced for the condition the patients are at

during rehabilitation. Changes were made to the original program to be better tailored towards
cardiopulmonary patients and improving aspects of balance relative to them. Graphics and
explanations of each balance exercise was made into a handout for patients to take home.
Progression was also explained on the handout, with an ultimate goal for patients to strive to
achieve for each balance exercise.
The balance training program was never introduced to the maintenance program
participants. The initial plan with the balance program was to do a group balance training
session during three to five maintenance program sessions for participants who were interested.
However, because of limited familiarity with balance and gait assessments, more time was
spent explaining and demonstrating the Tinetti Balance Assessment. There were a few
discussions with some classes about an introduction to a balance program and whether or not it
would be of interest to them. Overwhelmingly, the answer among the classes was that a
balance program would be beneficial. After having a positive response to a balance program,
the classes were then asked what aspects of balance they wanted to target. Most participants
stated that stability was an issue. Another common response was decreased proprioception. But
the main reason participants wanted to perform balance exercises is because they wanted to
decrease their risk for falling or decrease the likelihood of having another fall. Proposed
exercises were discussed with the participants, as well as the benefits of performing each
exercise. The importance of having an initial balance assessment done prior to beginning a
balance program was discussed with the participants. Proper progression for the patient with
the balance program is based off of how the patient scores for the balance and gait sections of
the Tinetti assessment. Also, each subcategory in those sections is reviewed and any areas
where the patient struggles would be addressed in the balance program.
Variation of risk classification between the current balance assessment protocol and the
Tinetti Balance Assessment could be due to the patients improvement in balance from cardiac
rehab to the maintenance program, technician error from the previous balance assessment
resulting in improper classification, inclusion of gait analysis which might be a strong suit of the
patient, or recovery of strength. The variation was a patient classified as high risk according to
the previous assessment and not classified as moderate risk according to Tinetti. There are just
as many factors that could be the cause of a patient being classified as low risk according to the
current protocol and having a higher fall risk classification according to the Tinetti protocol.
Inclusion of daily movements in the Tinetti Balance Assessment could contribute to a higher and
more accurate fall risk classification. Of the 13 participants assessed using the Tinetti Balance
Assessment, none of them were previously classified as a low fall risk and then classified as
moderate or high. Further research should be conducted with participants who were previously
classified as a low fall risk according to the current balance protocol compared to the
classification from the Tinetti Balance Assessment. Since the current assessment only looks at
blood pressure from sitting to standing, age, glaucoma/macular degeneration, and previous fall
history it would be expected that many of those patients would have a higher risk classification.
Baseline information collected from the 13 maintenance program participants allowed
the department to determine pros and cons of the assessment. In terms of administration, the
two biggest downfalls are subjective analysis and lack of gait analysis training. To make gait
analysis easier to assess for the staff, a physical therapist is going to come to the September 8th
staff meeting and instruct proper and efficient gait analysis. In order to make the subjective
analysis of the assessment most accurate between staff members an initial competency will be
conducted. Staff will each score the same patient performing the balance and gait exercises. A
discussion will take place on what each staff member saw in the patient. Where there are
disagreements in scoring, cues will be written down on what classifies a patient as one score
versus another score. If the staff cannot all be consistent with scoring then this balance
assessment will not be valid, and thus making the balance program less likely to improve the
patients balance.

Strengths of the balance assessment included quickness, ease of administration, fall risk
classifications, reliability, and ability of the assessment to look at typical activities done by
patients. The Tinetti Balance Assessment accurately identifies 93% of patients at risk for a fall,
with greater reliability shown in populations older than 65 years (Raiche). Strengths of the
balance program include progression, dynamic exercises, and benefits seen to elderly
populations. Patients older than 65 reduce their risk of falling or suffering a serious injury from a
fall by approximately 35-40% (Campbell).
Limitations of the assessment include variability in classification based upon subjective
observations, not as reliable for younger populations, and necessary training for staff to become
proficient in the assessment. Limitations of the balance program include progression being
based off of initial assessment classification, not as beneficial for younger populations, and
safety concerns for elderly patients performing exercises at home.
Further research and trials need to be completed where patients are progressed from
the initial balance assessment to performing the balance program through one progression.
From here the patients should be re-assessed according to the Tinetti Balance Assessment and
see if there is any change in fall risk classification. An improvement in fall risk classification
would be expected. If this improvement is not seen then modifications to the balance program
would need to be made or more individualization to each patients need for improvement would
have to be addressed.
Conclusion
The Tinetti Balance Assessment is reliable and valid for the cardiopulmonary patients.
Inclusion of daily movements makes the assessment applicable to the patients. And with an
accurate baseline assessment a balance program and proper progression is established for the
patient to see improvements. The Tinetti Balance Assessment has shown to be just as accurate
as the current balance assessment, if not more accurate. With proper training and
competencies in place, the Tinetti Balance Assessment and Otago Balance Program will be
great additions to the cardiopulmonary rehabilitation and exercise physiology department.

References
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rehabilitation for individuals with COPD. Chest, 144(6), 1803-1810. doi:10.1378/chest.13-1093
Butcher, S. J., Meshke, J. M., Sheppard, S. (2004). Reductions in functional balance,
coordination, and mobility measures among patients with stable chronic obstructive pulmonary
disease. Journal of Cardiopulmonary Rehabilitation; 24: 274-280. Doi: 10.1097/00008483
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Campbell, & Robertson. (2011). Exercise-based interventions: The otago exercise program.
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239-248
Mandic, S., Hodge C., Stevens, E., Walker, R., Nye, E. R., Body, D., Barclay, L., & Williams, M.
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Marques, A., Jacome, C., Cruz, J., Gabriel, R., & Figueiredo, D. (2015). Effects of a pulmonary
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Nantsupawat, N., Lane, P., Siangpraipunt, O., Gadwala, S., & Nugent, K. (2015). Gait
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Rocco, C. C., Sampaio, L. M., Stirbulov, R., & Correa, J. C. (2011). Neurophysiological aspects
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Stand to Sit Two Hands

Sit in a chair
Place your feet slightly in front of your
knees
Lean forward over your knees
Use hand(s) to help if necessary
Progression: eliminate the use of hands
when standing

One Leg Stand Hold Support

Stand up tall beside a table, hold on and

look ahead
Stand on one leg (if able)
Try to hold this position for 10 seconds
Stand on the other leg
Try to hold this position for 10 seconds
Progression: one leg stand up to 30
seconds

Toe Walking Hold Support

Stand up tall beside a table, hold on and

look ahead
Come up onto your toes and steady
yourself
Walk 10 steps on your toes
Slowly lower your heels to the ground and
turn around
Repeat
Progression: toe walking without support

Heel Toe Standing Hold Support

Stand up tall beside a table, hold on and

look ahead
Place one foot directly in front of the other
foot;
so feet form a straight line
Hold this position for 10 seconds
Place the foot behind directly in front of the
other
Heel
Walking
Hold
Support
Hold Toe
this position
for 10
seconds

Stand up tall beside a table, hold on and

look ahead
Place one foot directly in front of the other
foot
Place the foot behind directly in front of the
other foot
Repeat for 10 more steps
Walk backwards by moving the front foot to

Heel Walking Hold Support

Stand up tall beside a table, hold on and look

ahead
Come back onto your heels, raising your toes
off the floor
Steady yourself and walk 10 steps on your
heels
Slowly lower your toes to floor and turn
around
Repeat

Sideways Walking

Stand up tall near a table, hold on if

necessary
and look ahead
Take 10 steps to the left
Take 10 steps to the right
Repeat
Progression: sideways walking without
support

Stair Walking

Walking and Turning Around

Stand near a table, hold on for support

when necessary
Walk at your regular pace
Turn in a clockwise direction
Walk back to your starting position
Turn in a counter-clockwise direction
Progression: figure-8 without support

Comments:

Hold onto the handrail for support

Go up 4-5 stairs
Turn around
Go down 4-5 stairs to starting point,
repeat
Total stairs: 20-25
Progression: stair walking without
support

Otago Balance Training Program

Balance exercises can be performed every day. 1 set = 10 steps or 10 seconds x 5
repetitions.

Balance exercises can be performed every day. 1 set = 10 steps or seconds x 5 repetitions.

Date:
10
stands

10
stands

10
stands

10
stands

10
stands

2. Heel Toe
Standing

10 steps
x5

10 steps
x5

10 steps
x5

10 steps
x5

10 steps
x5

10 steps

3. One Leg
Stand

Progres
s to 30s
x5

Progres
s to 30s
x5

Progres
s to 30s
x5

Progres
s to 30s
x5

Progres
s to 30s
x5

Progress to 30

4. Heel Toe
Walking

10 steps
x5

10 steps
x5

10 steps
x5

10 steps
x5

10 steps
x5

10 steps

5. Toe Walking

10 steps
x5

10 steps
x5

10 steps
x5

10 steps
x5

10 steps
x5

10 steps

6. Heel Walking

10 steps
x5

10 steps
x5

10 steps
x5

10 steps
x5

10 steps
x5

10 steps

7. Sideways
Walking

10 steps
x5

10 steps
x5

10 steps
x5

10 steps
x5

10 steps
x5

10 steps

8. Walking w/
Turning Around

Figure-8
x5

Figure-8
x5

Figure-8
x5

Figure-8
x5

Figure-8
x5

Figure-8

9. Stair Walking

1 stair
1 stair
1 stair
1 stair
1 stair
climb x 5 climb x 5 climb x 5 climb x 5 climb x 5

1.Stand to Sit

10 stands

1 stair climb x