Cases

Essentially, STABLE is a method to personalize balance exercises. The overarching premise of the approach is that exercises prescribed to the patient should target the most compromised balance domain(s), because this/these domain(s) are the “the weaker link of the chain” and eventually define the patients overall balance ability and to which degree the patient is in risk of falls.

The six measures applied in STABLE measures balance ability on activity level and does not diagnose impairments of body structures. These possible impairments, which can be quantified applying diagnostic equipment or through other assessments, must also be regarded by the health professional when prescribing exercises to the patient.

Further, it is essential that the patient’s history and personal preferences is regarded.

Figure 1 shows the factors which should be regarded by the health professional when designing, prescribing and modifying an exercise program to any patient, applying STABLE.

In the following, two cases exemplifies how STABLE can be applied to design and implement an exercise-based treatment with a patient who has a relatively high functional capacity and a patient with less functional capacity. The two cases also illustrate how the DBAR approach can be applied to include and motivate the patient in the treatment and how different patients need different treatment.

Please notice that the method applied in the cases for producing the patients balance profiles are based on the “manual” approach. We now provide an online calculator to produce balance profiles. We recommend applying the online calculator for optimizing clinical applicability.

STABLE graphics

 

Case 1, Marie:

History and personal preferences

Marie is a 76 years old female. She had until recently a relative active lifestyle participating in multiple social events during the week, using the bicycle when commuting close to her residence and doing regular walks alone and with friends in the city or into the woods. Her spouse, who is 10 years older is less physical capable mostly due to arthritis and a progressed chronic obstructive pulmonary disease. For some years the couple has therefore depended on Marie´s ability to overcome the practicalities of the household.  

Last year Marie suffered from a sudden unset of rotational vertigo causing acute nausea, vomiting and inability to stand or walk unsupported. MRI scanning showed no sign of central nervous system involvement and Maria was eventually diagnosed with vestibular neuritis and discharged from the hospital after one day of observation.

The rotational vertigo diminished gradually, but one year after the onset of symptoms the event is still affecting her daily life. Thus, she is referred for assessment in a specialized dizziness and fall prevention clinic by her family physician. Marie reports that she is suffering from a constant feeling of lightheadedness which is worsened when she is tired or feeling more stressed than normal. She feels dizzy when moving her head for instance before crossing a road or turning around in the kitchen while cooking or cleaning. The dizziness is not a true spinning sensation, but rather a feeling of the brain moving separately in the skull and the body not responding adequately. After moving she feels dizzier and mentally tired. Therefore, Marie is avoiding as much as possible moving her head or turning her body. Marie also reports that she feels uncomfortable being in crowds or watching busy visual environments like the shelves in the supermarket. She feels less stable in the dark and always switch on the lights when she needs to get up at night. This was not necessary before the unset of symptoms. When crossing uneven surfaces like the lawn in the garden or a brick path she needs to move very careful not to stumble.

Marie has not experienced any falls in one year, but she states this is because she has been moving very cautious not exposing herself for any situations which could challenge her balance more than she felt was safe. Anyway, Marie reports multiple occasions of near falls, when she just managed to grab support or take multiple steps to regain balance. These events typically occurred when changing direction during walking or when bending over or turning to reach for items in the kitchen cupboard.

Marie´s lifestyle has changed dramatically within one year. Because she is afraid of falling, she is very seldom doing more than minor walks on her own. About six month ago she went for a walk in the forest close to her home with the same friends she has been walking with on a regular basis before the onset of symptoms, but she felt uncomfortable because she was afraid of falling and could not concentrate in the conversation while walking. Further, she felt that her dizziness was worsened after the walk, with the spinning sensation almost reoccurring, she felt very tired and believed that she was limiting her friends with her slower walking speed. Even though her friends have invited her multiple times since then, she has not gone for any longer walks since then. Marie is still participating in social events but not on regular basis and only if she can go by car or people can come to her home. She feels comfortable driving in known places if the traffic is not too dense, but she has not used the bicycle since the unset of symptoms. Lately, she has had trouble sleeping and she feels her memory is not the same as before. Marie wonder if this is because she is worrying to much.

Impairments of body structures and functions

In the medical examination vestibular caloric stimulation and video head impulse test confirm a vestibular hypofunction of the left ear. Further, biothesiometry shows a mild peripheral neuropathy in both feet. No other major impairments or signs of unknown disease are found but completing the Falls Efficacy Scale – International and the geriatric depression scale, Marie shows fear of falls and depression. Medication for depression is therefore discussed in the medical examination, but not prescribed.

Physical therapy assessment applying the DBAR approach

No further impairments of body structures and functions are found in the physical therapy assessment. Marie is capable of walking on toes and heels showing adequate overall strength of ankle joints. No pain is reported apart from stiffness in the neck, but passive and active range of motion is not compromised for any joints.

The six tests in the DBAR approach are completed:

Domain

Test

Score

Notes

Power

 

Adjusted sit to stand

7.9 seconds

No dizziness. No pain

Stability limits

Max reach (Relative score)

0.56

Mild dizziness when getting up from reaching position

Anticipatory turning

Turn and Touch test

23.6 seconds

Worsened dizziness. Turning “en bloc” keeping the head stationary

Reactive stepping

Reactive four-square step test

12.1 seconds

No dizziness. Some hesitation stepping backwards first time

Sensory orientation

Test of reference frame interaction in Balance

0.68

Mild nausea and afraid of falling with closed eyes

Cognitive-motor interaction

Cognitive TUG (Relative dual task cost)

4.3 %

Some sidestepping when turning in first attempt

The scores are plotted with the normative values showing Marie´s balance profile (blue crosses represent Marie´s scores):

Marie first assessment

The physical therapist discusses the findings and implications with Marie:

From Marie´s balance profile it is evident that her overall balance capacity is above mean compared with other balance impaired individuals. Marie´s capacity of turning (TAT) is the most compromised balance domain followed by sensory orientation (TRIB) and cognitive-motor interaction (cTUG).

The physical therapist discusses with Marie how the objective findings relate with Marie´s history and personal preferences. Marie´s symptoms while turning the body or head is most likely explained by the uncompensated unilateral vestibular hypofunction. Her balance especially without good visual and proprioceptive reference available, is further compromised likely because of the mild neuropathy. But because her overall balance ability is not compromised in a high degree, her ability to execute power is not compromised and she was used to an active lifestyle before the unset of symptoms, she has a good foundation for returning to a better functional capacity.

Based on the findings the physical therapist proposes a home-based exercise program targeting Marie´s most compromised balance domains (i.e. anticipatory turning and sensory orientation). Marie is instructed to perform two exercises 3-5 times a day in modules of 5-10 minutes:

  • Standing with the back to a corner tossing a small ball from one wall to the other while turning the head and body.
  • Standing with the back to a corner with eyes closed turning the body to touch the wall on each side with the opposite hand

A small brake of 15-30 second is incorporated in both exercises after 8-10 movements and the exercise is initiated again when the dizziness has returned to the level of before initiating the exercise.

In addition to the exercises a regular walking program is planned. Marie is advised to walk every day for minimum 15 minutes. In the beginning Marie can choose walking in known areas close to her home.

The physical therapist ensures that Marie understands the porpoise of the exercises and performs the exercises correctly and safely. Further, Marie is given a written instruction explaining the exercises with text and pictures. 

First physical therapy follow-up

After three weeks Marie returns for planned follow-up.

Marie reports that in the first week of doing exercises her dizziness worsened and she felt more tired, but the last week she started feeling less dizzy when walking and especially turning the head is now less bothersome. She has been walking almost every day close to her home but has not yet been walking with her friends or used the bike. Marie reports no falls.

The physical therapist now progresses the exercises incorporating dual-task elements (which was the third most compromised domain in Marie´s balance profile) and challenging her sensory orientation even more:

  • With the back to a corner tossing a small ball from one wall to the other while turning the head and body. At the same walking on the spot.
  • Standing on a thin foam plate with the back to a corner with eyes closed turning the body to touch the wall on each side with the opposite hand. Alternating between performing the task very slowly and as fast as possible

Marie is additionally advised to expand her walking program to locations further away from her home. Preferable public areas. 

Second physical therapy follow-up

Six weeks after the physical therapy assessment Marie returns for planned follow-up.

Marie reports that overall, she feels better. The movement induced dizziness bothers her much less. If she moves a lot around turning her head continuously, she gets dizzy, but normal daily routines do not bother her anymore if she doesn´t hurry to much. Marie is walking every day and she even went for a walk with her friends. She still not feels able to concentrate completely about the conversation while walking, but the constant unsteadiness is much less. The dizziness induced by busy visual environments has also diminished, although not completely gone. Marie states that understanding that her symptoms are due to her vestibular loss and impaired sensory orientation – not because she was getting crazy – also helps her and somehow makes the symptoms diminish.

The physical therapist now progresses the exercises:

  • In a corner doing full body turns in alternating directions and tossing a ball on each wall after completing a turn. Randomly changing were she hits the wall and which wall she hits.
  • On a thin foam plate with the back to a corner walking on the spot with the head facing in random directions. Closing the eyes 3-5 steps at the time.

Further, Marie is advised to deliberately seek to walk in busy environments and staying physically active as much as possible.

Third and final physical therapy follow-up  

Four months after the physical therapy assessment Marie returns for planned follow-up.

Marie reports, that although she does not feel completely the same as before the unset of symptoms, her lifestyle is very similar with the way it was before the unset of symptoms. The movement induced unsteadiness is not present anymore when she moves about inside her home or on solid ground outside. On uneven or soft ground, she still needs to pay more attention to keep stable, but she doesn´t feel in risk of falls. Marie still prefers turning on the lights when getting up at night. She believes this is more because of a habit, but she also feels safer this way. Marie has gone for a bike ride twice in a major park close to her home. This went surprisingly well, but she doesn´t feel ready for commuting in the traffic yet. Being in visually busy environments doesn´t bother her significantly anymore, so she does not avoid social events. After a day with a lot of activity she still feels more tired than before the unset of symptoms.

The six tests in the DBAR approach are re-tested and plotted with the normative values (blue crosses represent Marie´s first scores and red crosses represent the second assessment):

Domain

Test

Score

Notes

Power

 

Adjusted sit to stand

8.1 seconds

No dizziness. No pain

Stability limits

Max reach (Relative score)

0.57

No dizziness

Anticipatory turning

Turn and Touch test

11.5 seconds

Some dizziness. 10-15 seconds after turning

Reactive stepping

Reactive four-square step test

10.7 seconds

No dizziness. No hesitation

Sensory orientation

Test of reference frame interaction in Balance

0.79

 

Cognitive-motor interaction

Cognitive TUG (Relative dual task cost)

-1.2 %

 

Marie second assessmentThe physical therapist discusses the findings and implications with Marie.

From Marie´s new balance profile it is evident that she has improved mostly what she had practiced. Marie´s capacity of turning is better. This relates with Marie´s diminished movement induced dizziness. Like so, Marie´s sensory orientation has improved, which relates with her subjective perception of improved balance on unsteady ground and in the dark and less dizziness when exposed to complex visual environments. The score of other domains have changed as well, but within the measurement error of the tests. From Marie´s new balance profile it is now evident that the domains “stability limits”, “sensory orientation” and cognitive-motor interaction are relatively more compromised.

Based on Marie´s new balance profile the physical therapist composes one exercise targeting these most compromised domains, which Marie is advised to perform on a regular basis:

  • Standing with the back to a corner with eyes closed turning the body to touch the wall on each side with the opposite hand. Reaching as far out, in, up and down as possible. At the same time speaking out loud a color for each direction (i.e. saying “blue” when reaching up, saying “yellow” when reaching to the left, saying “red” when reaching down and so on)

Further, Marie is advised continuing to commute in busy environments on regular basis. She is advised to practice biking wearing a helmet in the park doing sharp turns, turning the head going straight and breaking. No biking in the traffic should be initiated before she feels completely safe on the bike. The physical therapist explains that the dizziness and tiredness can vary depending on multiple factors. Marie should stay physically active as much as possible but also allow herself to rest when she needs it.

Marie is offered a six-month follow-up consultation for re-test and evaluation.

 

 

Case 2, Erik:

History and personal preferences:

Erik is a 68 years old male. Erik started working in a young age and has done physically hard work most of his life. In his spare time Erik hasn´t found much time for physical activity but even though he has been a smoker and enjoys having some beers with friends, he feels that he has been quite physically fit most of his life. In Erik´s late fifties Erik was diagnosed with diabetes. He admits that maybe he wasn´t taking the disease quite serious in the beginning, not being very careful with his medication and not being that keen on cutting sugars, alcohol or changing lifestyle. Erik can´t remember when he started having balance problems. He remembers no acute event of dizziness or other acute symptoms, but about ten years ago he perceived that his balance had deteriorated and he had to pay more attention to where he was walking, not to stumble. In the meanwhile, his balance has just worsened.

Erik has experienced multiple falls. He states that he sometimes falls multiple times a day and at least fifty times during the last six months. He can´t consistently explain the reason for falling. Sometimes he just finds himself on the ground for no specific reason, but because he is normally able to get up again right after the fall, he is sure that the falls are never due to loss of consciousness. Some falls have been minor events. For instance, he often falls back into the chair when trying to get up. Other falls have had greater consequences of pain and minor fractures. Erik still suffers from compromised range of motion and pain from a wrist fracture of the right hand. Erik states that the fall causing the fracture was due to stumble in a carpet in the Livingroom. He believes that tumbling is probably the most common reason for falling. Erik is constantly monitoring the ground for any variations in the levels of the surface. A boardwalk tile which is not perfectly level can make him fall and sometimes even level ground “catches” the feet while walking. When he stumbles it is like the feet don’t obey to move fast enough to regain balance, he can only try to hit the ground with as less damage as possible.

Erik lives alone but seldom leaves his apartment. He has a walker for using outside, but he prefers to stay at home when possible and mostly order groceries online. During the last couple of years, Erik has attended two rehabilitation programs based on physical exercises. He explains that this somehow improved his balance and general wellbeing, but after the two months rehabilitation period was completed his balance seems to deteriorate again quite fast. Erik has been advised to join a fitness center to maintain his functional capacities, but he feels that he has never been that much into exercising and believes “it’s too much hassle getting to the place just to sweat”. He remembers that he was advised to perform three times ten stands from a chair every day as a home exercise, but he tried this only a couple of times because he couldn´t really see the point in doing this.

Impairments of body structures and functions

In the medical examination, biothesiometry shows a severe neuropathy of both feet. Strength is significantly reduced in both lower extremities especially in flexion and extension of the feet. Reaction time is reduced, and visual acuity is also below the expected. Blood tests show that Erik possibly still is drinking more beer than advisable. No signs of vestibular impairment are noticed. An MRI shows more degenerative changes and hypotrophy of the brain than expected from Erik´s age, but no signs of focal lesions.

Physical therapy assessment applying the DBAR approach

Normal manual head impulse test and dynamic visual acuity test confirm no signs of vestibular impairment.

When walking, a tendency of foot drop and impaired foot movement in the stance face is noticed. Erik can´t walk on his toes and heels without support and just barely when supported by placing the hand on the physical therapist’s shoulder. Erik can´t get up from a seat without supporting on the armrests.

No pain is reported apart from occasional lower back pain.

The six tests in the DBAR approach are completed and plotted with the normative values (blue crosses represent Erik´s scores):

Domain

Test

Score

Notes

Power

 

Adjusted sit to stand

15.6 seconds

No dizziness. No pain. Mild dyspnoea

Stability limits

Max reach (Relative score)

0.43

No dizziness, but excessive sway.

Needs multiple attempts with great variance of performance

Anticipatory turning

Turn and Touch test

27.3 seconds

No dizziness, but excessive sway. Taking multiple small steps using the arms for balance

Reactive stepping

Reactive four-square step test

32.0 seconds

No dizziness. Stepping on the cords going backwards. Needs support from assessor to regain balance in first attempt

Sensory orientation

Test of reference frame interaction in Balance

0.63

No dizziness. Unable of one leg stance

Cognitive-motor interaction

Cognitive TUG (Relative dual task cost)

41.1 %

Classifies some words incorrectly

Erik first assessmentThe physical therapist discusses the findings and implications with Erik.

From Eriks´s balance profile it is evident that his overall balance capacity is below mean compared with other balance impaired individuals. Although all domains are compromised, especially reactive stepping (rFSST) and stability limits (mReach) are severely compromised. This relates with the finding of Erik´s impaired sensory-motor control in the ankles and his experiences with falling because of obstacles in the ground and inability of taking fast compensatory steps. Erik´s power execution is limited, but not to the extent that he is not capable of supporting his own weight. His ability to turn is neither adequate but when he moves with caution turning is not the main risk of falls.

Based on the findings the physical therapist proposes a home-based exercise program targeting Erik´s most compromised balance domains (i.e. reactive stepping and stability limits). Because the impaired sensory-motor control of the ankles is the most likely cause of the compromised stability limits this bodily impairment is initially targeted in the exercises.

Erik is instructed to perform two exercises 5-10 times a day in modules of 1-5 minutes:

  • With the back to a corner stepping over a cord on the floor
  • With the back to a corner touching one wall for support, walking on toes and heels

Erik is instructed to perform the exercises multiple times a day. The physical therapist explains that It is not important to exercise continuously for a long time, but better doing the exercises in small modules every time Erik is bored for instance while waiting for the coffee water to boil.

In addition to the exercises a regular walking program is planned. Erik and the physical therapist agree that Erik should get out walking every day. The distance, destination or time doesn´t matter as long as Erik walks outside his home every day. The walker should be used for all walks.

The physical therapist ensures that Erik performs the exercises correctly and safely and Erik is given a written instruction explaining the exercises with text and pictures.

First physical therapy follow-up

After one week, Erik returns for planned follow-up.

Erik reports that he had partly adhered to the instructions. He has been exercising most days, but some days he didn´t. In the weekend the weather was bad, so he didn´t feel like leaving the home, but then he did the exercises five times Saturday. Erik states that he gets quite tired when walking on toes and heels but the stepping exercise is alright to perform.

Erik reports two falls in the past week. One was while entering a small convenience store after leaving the walker outside. The other fall was due to tripping while passing a doorstep. Erik was able to get up with some help from others at both occasions. Erik states with some irony that he is becoming a “professional faller”, that is why he seldom gets fractures.

The physical therapist explains that the tiredness after doing the exercises is good and proves that the exercises indeed are targeting what Erik needs to improve to get better.

The physical therapist evaluates how Erik performs the exercises and the exercises are progressed targeting the same domains

  • With the back to a corner stepping over a line of 5 plastic cups on the floor (the cups are lightweight and breakable if stepping on the cups)
  • With the back to a corner touching one wall for support, walking on toes and heels

Just outside Erik´s apartment there is a lawn which is quite even and well maintained. Erik and the physical therapist agree that Erik should practice walking in the grass 2-3 meter between the walker and a bench paying attention of lifting the feet. Additionally, Erik agree upon leaving the apartment for minimum one hour every day.

During the following three months four physical therapy follow-ups are completed. Erik shows varying adherence to the exercises and walking program, but overall improvement in the performance of the exercises. Thus, the exercises can gradually be advanced still targeting the domains reactive stepping and stability limits. 

Fifth physical therapy follow-up

Erik returns for planned follow-up.

He reports that there have been no falls in two weeks. Erik explains that he experienced multiple times of near falls, but he was able to take a fast step to regain balance. Also, he has noticed that he tends to hold less on to his furniture when ambulating inside his apartment. Although Erik is happy with his improvement, he emphasizes that he does not feel completely stable and still needs to pay attention to how and where he is walking.

For obtaining an objective status the six tests in the DBAR approach are re-tested and plotted with the normative values (blue crosses represent Erik´s first scores and red crosses represent the re-test scores):

Domain

Test

Score

Notes

Power

 

Adjusted sit to stand

13.3 seconds

 

Stability limits

Max reach (Relative score)

0.48

Reach maximal distance in 5 attempts.

Anticipatory turning

Turn and Touch test

22.6 seconds

Not very excessive sway. Completing each turn with 5-6 steps

Reactive stepping

Reactive four-square step test

22.9 seconds

Completing without touching cords. Some sway going backwards

Sensory orientation

Test of reference frame interaction in Balance

0.66

No dizziness. Unable of one leg stance

Cognitive-motor interaction

Cognitive TUG (Relative dual task cost)

30.4 %

Classify some words incorrectly

Erik second assessment

 

Erik is happy to receive prove that doing the exercises has improved his balance. The physical therapist confirms that Erik is objectively better at moving the feet to regain balance and controlling his center of mass in the extreme of the base of support. Also, Erik´s ability to turn seems to have improved even though he hasn´t practiced exercises directly related with this domain. The physical therapist explains that this is because of some interrelatedness between the balance domains. What is practiced to improve something often has some additional positive effect on other abilities.

Although improved, reactive stepping and stability limits are still the domains relatively more affected.

The exercise program is adjusted according to Erik´s new balance profile:

  • With the back to a corner stepping over a line of 5 plastic cups on the floor (the cups are lightweight and breakable if stepping on the cups). Stepping sideways, forward and backward. Not looking down at the cups for 2-4 steps at a time.
  • With the back to a corner touching a plastic cup with the heel of one foot while keeping balance on the other foot
  • With the back to a corner reaching out to place a plastic cup as far away as possible without moving the feet. After standing up, recollecting the cup and again placing it as far away possible in a new direction.

Erik has established a route around the apartment complex he is living, which he completes almost every day. Now he is advised to practice walking the same route without the walker. The physical therapist has previously proposed using a cane for walking, but Erik feels it´s getting in the way and it doesn´t feel safer using it.

Sixth physical therapy follow-up

Encouraged by the objective improvement documented in the previous consultation, Erik has become even more keen with the exercises and his daily walking routine. Overall, he feels more confident ambulating and doing daily routines. Unfortunately, he has maybe become too confident with his improved balance and experienced a fall while he was repairing an old car, which has been broken for years and stored at a friend’s place. Erik is getting much more around. He uses public transport frequently, bringing the walker and sometimes ambulating close to his residence without the walker.

Erik is performing the exercises once a day using 10-15 minutes. Even though exercising multiple times a day of shorter duration was less tiring, he now prefers to “get over” with the exercises in the morning and use the day for something else.

No changes are applied to the instructed exercises, but the physical therapist encourages Erik to challenge himself performing the exercises faster without compromising precision or safety.

Seventh and physical therapy follow-up

Six months after the initial physical therapy assessment Erik returns for planned follow-up. Erik reports that he hasn´t experienced any serious falls since the incident with the car at his friend’s place. He still occasionally experiences falling back into the seat if getting up fast or starting to move right away after standing. The frequent sidestepping to avoid falling is still present especially if he doesn´t “plan” where to walk before walking, but he doesn´t perceive this compensatory strategy of near falls anymore.

The six tests in the DBAR approach are re-tested and plotted with the normative values (blue crosses represent Erik´s initial scores and red crosses represent the second re-test scores):

Domain

Test

Score

Notes

Power

 

Adjusted sit to stand

14.0 seconds

Some dysnoea

Stability limits

Max reach (Relative score)

0.54

Reach maximal distance in 4 attempts.

Anticipatory turning

Turn and Touch test

20.5 seconds

Not very excessive sway. Completing each turn with 5-6 steps

Reactive stepping

Reactive four-square step test

13.7 seconds

Performs safely.

Sensory orientation

Test of reference frame interaction in Balance

0.7

No dizziness. Able of one leg stance on floor, open eyes

Cognitive-motor interaction

Cognitive TUG (Relative dual task cost)

25.2 %

 

Erik last assessment

 

From Erik´s new balance profile it is evident that reactive stepping and stability limits have improved. The physical therapist explains that the score of reactive stepping is now on the “right” side of the limits that is known to be closely related with fall risk. The balance profile also shows that Cognitive-motor interaction and power now are the relatively more compromised domains. The physical therapist and Erik conclude that now there is no way around the sit to stand exercise, which he has been instructed to do before but didn´t saw the point in doing. One exercise with an extension is instructed and prescribed based on Erik´s new balance profile:

  • Standing from a chair with the height of the seat adjusted with pillows until standing can be completed without using the hands to push of the armrests. The stand is completed as fast and explosive as possible emphasizing leaning the body forward before standing. Sitting is completed in slower speed controlling especially the final phase of the movement. The stands should be repeated 3 sets of 10 repetitions, minimum 3 times a day.
  • The same exercise as above, but executed while 1) changing a small ball from one hand to the other, or 2) naming words starting with the letter “p”

Erik is additionally advised to keep enhancing his overall physical condition and balance by walking every day experimenting walking outside without the walker on well-known areas where he feels he is in low risk of falls.

Eighth and final physical therapy follow-up

Three weeks after the previous follow-up Erik returns.

Erik reports that he is still keen with the exercises performing them almost every day and he is able to show how he performs the exercises correctly. Most days he completes the stand exercise three times a day, some days even more times. Additionally, Erik has invented a variation of the cognitive task, remembering names of people he has known. He reports no falls since the previous consultation.

No reassessment is done in this consultation, because significant improvement is not expected within the short time since previous consultation.

Erik is instructed to keep with the same exercise and walking routine, but adding one additional exercise for improving power execution even more:

  • Walking on stairs holding the railing lightly all the way to the top floor (5th) of his apartment complex minimum three times a day

Erik is offered returning for consultation if he experiences any deterioration of balance capacity within one year.


Print