Applying STABLE

This sections describes our recommendations for applying STABLE. The recommendations described under "initial consultation" is normally completed within one consultation, but can be divided between more consultation if preferred by the patient or the health professional. Two illustrative examples of applying STABLE are provided in cases (applying the manual method for producing the STABLE balance profile).

Recommendations for the initial consultation

1. Complete a throughout anamnesis

Understand the nature of the patients' balance problems or dizziness. How and when did the symptoms start? What worsens the symptoms? What alleviates the symptoms? If any falls, what were the circumstances for these. How does the patient adapt to the balance impairments or dizziness in daily life?

2. Complete relevant examination of body structures and functions

Depending of previous completed work up and the patients' history examine the range of movement of the neck and lower extremities, sensibility of feet, strength of ankle and hip muscles, vestibular system and vision.

3. Complete the six measures

Please follow the instructions stated in the measures section and note results.

4. Produce the balance profile.

We currently offer two methods for producing the STABLE balance profile. The two methods produces conceptually identical profiles but with distinct graphical presentation.

The profile can be produced manually by applying the scheme of the normative values plotted by interquartile ranges. The scheme can be accessed in normative values.

Alternatively, the profile can be produced applying the online calculator.

5. Interpret the balance profile

Explain the interpretation of the balance profile to the patient.

Discuss which domains are more compromised and which are less compromised. Discuss how the profile relates to the patients' perception of balance and dizziness and how the profile relates to the patients' known impairments of body structures and functions.

Conclude what will be the domain in focus of the intervention and define a goal of the intervention (about choosing the domain in focus, please refer to introduction to STABLE).

6. Chose or design exercises or other intervention targeting the domain in focus

Examples of exercises targeting each domain and recommendations for prescription can be found in introduction to exercises.

7. Instruct the exercises

To ensure correct execution of the exercises and optimize the adherence and safety we recommend the following procedure:

  1. Show the first exercise
  2. Let the patient execute the exercise
  3. Make necessary corrections or adjustments
  4. Let the patient execute the exercise correctly
  5. If relevant, instruct a second or more exercise(s) applying the same procedure
  6. Discuss the number of repetitions in each set, how to include short brakes in each set and the number of daily sets
  7. Provide written instructions about the exercise(s)
  8. Schedule follow up consultation

We recommend that no exercises should be prescribed to any patient without seeing the patient performing the exercise. This is the only way to ensure that the patient understands how to execute the exercise correctly and to ensure the safety of patient. Further, memorizing important details of the exercise is much more likely when "the body's memory" is activated.

The optimal number of exercises preferably prescribed is individual. We prefer to prescribe only a few exercises, to insure that the patient understands, memorizes and prioritizes them in the daily routine. One exercise can be sufficient in the first consultation and we recommend that the patients' complete exercise program doesn't exceed three exercises at any given time during the time of rehabilitation.

Written information can be given following various approaches. For patients with no cognitive impairments, letting the patient take notes by writing or drawing can be a good option which can promote the patients' understanding of the exercise even further. For elderly patients it is often preferable to hand out written instructions with illustrative picture(s). One approach is to gather a collection of key exercises instructions which contains room for adding notes about adjustments or specifications. Another approach is letting the patient or relatives who may accompany the patient at the consultation video record the exercise with a smartphone.

Always schedule a follow up consultation. It is very unlikely that any patient after one initial consultation can perform all instructed exercises completely correct, at the right number of repetitions and sets, progressing the exercise(s) correctly without compromising safety and have no doubts about the execution. Exercises which might be logical and easy to perform for a health professional who is experienced treating balance impairment or dizziness may not be easily understood by the patient. And even if a perfect instruction is provided, written information is given and it is insured that the patient can perform the exercise without any supervision before leaving the consultation it often becomes evident at the follow up consultation that fundamental elements of the exercise is misinterpreted or forgotten by the patient. 

Recommendations for progression of exercises in subsequent follow up consultations are given in introduction to exercises.

Recommendations for the concluding consultation

1. Complete the six measures and compute the scores 

Follow the same procedures as in the initial assessment 

2. Produce the balance profile

If applying the manual method, compute the scores and plot the scores with the same normative values as applied in the initial assessment. The scores from the second assessment can preferably be plottet with the scores from the initial assessment using two colours. 

If applying the online calculator, choose the "two assessments" option and enter the values from the initial assessment and the second assessment.

3. Interpret the balance profile

Explain the interpretation of the balance profile to the patient.

Discuss the objective changes with the patient. Did the patient improve in the domain(s) which has been in focus of the intervention? Did the patient improve or deteriorate in any domains?

Discuss how the objective changes relates with the patient' current subjective perception of balance and dizziness. 

4. Plan maintaining procedures

Based on the observed changes and the new balance profile, discuss wether further intervention are warranted. If the conclusion is yes, decide with the patient wether the domain in focus should change. This may be the case if improvement in the domain which has been in focus caused that another domain now is relatively more compromised and it is likely that the patient can improve more.

If no more consultations are planned discuss which of the patients' known exercises should be continued or if other physical activities in daily living (which the patient has accomplished to perform through the rehabilitation period) is sufficient for maintaining the acquired improvement.