(whimsical music)
- Hello, I'm Bob Schrupp, physical therapist.
- And I am Brad Heineck, physical therapist.
- Wow, he's emphasizing that.
Together, unless he doesn't even want me around anymore,
we are the most famous physical therapists
on the internet.
- Yeah, and that's in our opinion, of course,
but it could happen where I get to be
the most famous, someday.
- We do have some unity here.
We're both wearing our Jerry Garcia ties today.
- They probably noticed that right away.
- Yeah. They picked up on that.
So today Brad, we're going to talk
about the Tinetti balance assessment tool or,
Tinetti assessment tool
or I'm not sure what all it's called.
(taps board)
- Very nice.
- Invented by? - Mary Tinetti.
And she's a physician and where did you say
she is right now?
- Well, I know she had some involvement
at the University of Minnesota.
I don't know if she's still there or was there but
- Somewhere in this region.
- We're from... I'm from Minnesota, he's from Wisconsin.
- Yeah. She probably started at Madison, Wisconsin.
- Oh, I bet. I bet.
- Anyway, why this might be of interest to you
if you have anybody that you know
or yourself that you're having trouble
with balance and you're worried that they may fall.
That's what this test is to help.
- Sure.
- Try to predict. Very difficult to do
but we use it all the time.
It's our probably most standard test that we use
to see if someone's going to fall.
It's not that you have to do the test
but we're going to show you components that might
help you look at your mom or dad and say,
Boy, he may be at a risk for falling.
- Sure. And now are you have a quick little assessment
just to get a rough idea.
- Yeah.
- But you know, as far as the Tinetti test goes,
there's a score on it.
And when we use it clinically, we have a score
and it's nice to have some objective numbers and say,
You know, as we take our test
we get a hundred percent.
We're real happy.
Well, it's not.
So on the Tinetti the highest score on the Tinetti is a 28.
The lowest score would be a zero.
And if you, the 19 range, if you're at 19
that's kind of that gray zone where you could be you're
at that high fall risk to do you need a cane?
Do you need a walker?
Or, you know, if you're down at the five and six range
chances are that person has been falling already.
- Has really fallen already, and if you've fallen already
that means you are at high risk for falling.
- Right.
- I mean, that's automatic.
If you've fallen already, you are at a high risk.
And generally, I don't know if you run it this way, Brad
but when someone's at a 19 or above or 19 and below
I generally think they should be using a walker or a cane.
- Right there are exceptions.
- There are exceptions.
There's always exceptions.
But, but as a rule, sure.
I would say, okay, Brad, I guess I'm going to be the patient
and you're going to be the clinician.
And you're going to take me through it.
And the first one we do is I'll
I'll just read it first, this each step.
- Sure.
- And you'll, you'll determine what, how I do on it.
- Okay.
- Okay. Well, it's divided into two sections
and the first one is...
- Balance section.
- Balance. So it's just looking at, at balance and
it's interesting because part
of the balance is people don't always think
about it is sitting, you have balance when you're sitting
you don't tip over in the chair, which you know
most people don't even think about
but with people with trunk weakness.
- We have people that are just that.
Or if it says leans or slides in the chair.
Or just having trouble maintaining their balance.
- Exactly.
So you can get one point, if you have good balance
and you have zero points, if you don't
- And typically this test is for people that, you know
elderly and 60 or 70 years old and older
or if someone has some weaknesses
or some deficits, cerebral palsy, something of that would
this would be adequate for
or just getting out of a surgery.
And they're still in that week stage.
- This is another good one, rising from a chair.
We measure how well they rise out of a chair.
- Right. And what we do is, this is how I do this one.
I have them sit like Bob is, and I ask the person
can you put your hands together like this?
And can you arise like that?
And if they sometimes multiple attempts
sometimes it cannot get up at all and...
- Sometimes they have to use,
- Right. And if... yep arms
- Arm rest, or I guess this would even count as arms, right?
- Yeah. If they're doing that, then I'm going to dock
them a half a point.
Okay. We're not going to get
into those details with, with these people
unless your a therapist.
- What does that mean, Brad, though
if they're having trouble getting up?
- Typically it means strength,
- Right.
- Strength in the legs. They don't have the strength
in the quads and the glutes to, to get up.
- And if they don't have the strength
in the quads and glutes that means they are going to be
at a higher risk for falling generally.
Cause you get a lot of your balance from
from this area. Could also be pain, which is the same thing.
Pain can cause you to lose your balance.
If you have bad knees, bad hips.
- Sure.
You know? So...
- And then once they get up,
- We want to read the next section is attempts to rise
immediate standing balances.
Right. So at that point we just have the person look,
Are they wobbly?
Okay. If they're doing that, they gotta catch themselves.
That's going to change the score a little bit.
- If they fall, which we
always have a belt on when we're testing them.
If they get up and they actually, you know
they get zero points then.
- Right? Exactly.
- If they catch themselves, they get one.
- Right.
- And if they're solid?
- Two.
- Two. Okay
- So, and then at that point I can go, I got this.
- You sure.
- Oh yeah.
- All right.
- I got it memorized, Bob.
Don't worry about it.
- I want to make sure he's right.
- Bob... Have faith in me.
- Okay.
- You just you'll yeah. It'll come. just now.
The next thing is you have them put their feet together
close together.
- See, you're missing a section.
- What?
- You're missing immediate standing balance.
- Yeah.
- Standing balance, narrow base. Oh yeah. You're right.
(Brad Laughing)
- I thought you were doing the nudged right away.
- Well, of course not, then it's feet together.
Now this one, a lot of people
because of the growth of their legs,
or if they're knock kneed,
they cannot get their feet to touch.
- Right.
- But you get as close,
- As close as you can.
- Right. And then just stand there and see how
they balance at that point.
And then we go to, I go to eyes closed.
This isn't in order with the test,
but this is the way I do it.
Eyes closed for three seconds.
Can you close your eyes, Bob?
1, 2, 3.
And this one, you know, Bob is steady
but this really pops up.
- Gets a lot of people.
Yep. They close your eyes and there grabbing it
- Going back to even the narrow base, one, Brad
very common for people to lose their balance
on that one too. They're fine,
As long as they keep their legs apart.
- Yeah.
- But when you go narrow base like this
you're really relying on your ankles.
- Sure.
- And a lot of people don't have that
proprioceptive sense or whatever
the sense of where they are at.
And so they really start swaying on this.
And that means they're 'cause
during the day you're going to have points where
you have your feet together, like this,
- There you go
- Doing when you're doing things
in the bathroom or whatever, so...
- Right.
- Exactly. Feet together again.
And the next is a sternal nudge.
And a lot of people, especially the older people
if they fall, backwards is a direction they're going to go.
So we want to make sure they're steady there.
So you go here and you're just, yep.
Just three, three, nudges is what the test requires.
A lot of times, if I want a little more
I kind of go outside the test home and I'll push...
- That's what I do too
- different areas.
- I push in every different direction.
- And at that point
some people push me back and say, what are you doing?
(both laughing)
No, that happened once she did, had a woman,
she got upset with me 'cause she thought I was being rude.
(both laughing)
I didn't explain myself well.
But if they catch themselves they still get a point.
- Right.
- If they don't catch themselves and you, again
you have to hold onto their belt.
- Right.
- Then they get zero points.
And if they hold strong, they get two points.
- So, okay then the next one eyes are open
and it's the 360 degree turn.
Now this one, if you don't.
- Legs are apart.
- Yep. I have them bring their legs apart.
This is the one where I have nurses do.
I say you don't have to know the test
but if you just want a good sense
if the person needs an assisted device, a walker or a cane
this is a really good one.
Or if they can be in their house by themselves
turn around without touching anything.
And if they can do that with confidence
and you can feel like you don't have to do anything.
Yeah. But if you're like here, a lot of times on this one
I'll have another therapist
or another person stand right there
and I'm here and we have our arms
like this and we'll say, can you turn around?
- They can go down and go down.
The other thing
it needs to be continuous to get all the points.
- Right.
- If they're stopping, you know that means their balance.
Isn't as good as opposed to someone who can go like this.
Yeah. So,
- And another one they'll pivot
on one foot, you know?
- Oh sure.
Cause they don't want to pick that foot up.
- Yeah. They have one foot that's weaker.
There's an issue with it.
And you'll kind of favor that side and then sitting
down from there can the person and I'll actually have
them do this just 'cause I'm consistent that way.
If they, if they're ploppers, if they plop down
it's no good, weak, weakness.
- Weakness or again, possibly pain.
- Right.
- If you start getting pain and it just
you're going to plop right down.
- And that's a real good way to get a back problem,
compression fracture and some of those elderly people
and they plop down in a harder
- Or they can miss the chair, which would be a disaster.
- Yeah.
- So, cause you know, they're backing up and they
they don't put their hand back there.
They could slide right off and...
- So that concludes the balance section
- Balance section.
- And the total points you can get is 12.
- Is that right?
- Yep.
- Nope 16.
- 12 on the top 16 on the bottom
- 16 on the top.
- Oh 12 on the bottom
- 12 on the bottom.
- Yeah. Okay. I had that part mixed up
- Bet your glad I had this cheat sheet here aren't you now?
- Yeah...Yeah...
- And the next section is the gait section
or walking section maybe to the lay person and yeah.
You can get 12 points on that.
So remember the first part?
No hesitancy.
So we're up, we're up already, right?
- Yeah. After the, person's up in this one
I'll... depends on the person.
You have to have a sense.
Do they need, sometimes you have a walker right away.
- Right.
- They're just not going to be able
to walk without a walker.
- You know that they're not going to be able.
Right. They're just going to be so unsteady.
- Right. So, but we're going to do this
without a system device.
- Right. And so the first part is the hesitancy.
Yeah. And where we often see that is
in people with Parkinson's they just, a person with
Parkinson's just the way their mind works
and the way things work
they just can't get the muscles to cooperate.
And so they're just, they can't get things going.
I don't know of another instance
in which that would mean the case, would you?
- Yeah. That one is certainly prevalent.
Right? You get that.
They, they want to go and you can
and then finally they they'll start to get that shuffling.
And obviously that's going to take away a point
if they do hesitate.
- Right.
- Okay. And then it's step length.
- Yeah.
- Okay. So then we're going to look at walking.
- Could you zoom down here, Nancy?
So stride length or step length.
Why don't you set this foot here, Bob and then freeze.
So here's his toe line. I call this the toe line here.
If this foot passes the front of the toe here
then that's what I,
- so I should be more like this.
I mean that I definitely pass it now.
- Right, right.
And this is where it gets kind of hard to
judge cause a person's walking,
You can't have him stop
like Bob going here for educational purposes.
But that's if the foot passes the other foot
and if both feet pass the other foot
with a nice smooth motion, that's maximum point.
- Yeah. You get a point there.
You get a point there if you're passing
- But the person isn't doing that we're as you're walking
we don't have enough room.
As you're walking, you have to take all this in.
It just takes a little practice as a therapist.
It's hard to do this.
- But think about if you have poor balance
what are your going to try to do?
You're going to try to keep your feet on the ground.
- Yeah.
- And you're not going to want to take long steps.
You're going to want to keep real grounded.
If you have good balance, you can do things
like this, you know, and you take long steps
and you're balancing on one foot even for a while.
- Exactly.
- So the next one is Brad that's clearance. Right?
- Right. Do you drag when you walk?
- Yep. Are you dragging one of your feet
or both of your feet or again are your feet clearing?
Which means you actually have to balance
on one foot for a while.
- Yep. So sometimes the toe will drag,
sometimes the heel will come through
and drag and I'll count that off too.
- Do you cue people or not?
Cause I... a lot of times I will ask people, can you
can you take long steps and they're able to do so.
And then I'll just mark it down that I cued them
but they were able to do it.
- Yeah. Usually I just do their normal.
- Do it when their walking.
- Right. But yeah.
I could see where that would be...
- 'Cause some people do it.
Some people have what was a habit.
It seems like they should help the
- Or if they got slippers
on their slipper drops off their foot and drags.
- Oh yeah. Which is not that uncommon.
- Right.
- Get a lot of trouble with slowing and such, so.
Okay. Where are we at now Brad?
- Oh boy path. Oh aviation.
- Yeah. When they're walking, are they?
Yeah. It's almost like a drunk pattern.
- Right.
- So in that one, you know
that also has the gait aid on there too.
- Right?
- Yeah.
- If they don't, if they have a gait aid,
you get a zero on that one.
- If you're using any type of walker or cane
unfortunately you get marked down right away.
I mean, 'cause that's just how the test is.
So all right. Trunk marked sway.
- This is a, I don't, this is that one.
you know they talk about hands.
I know what they're talking about
but I don't see that very often on this one.
- Yeah I don't either.
- I think we should, you know
this is something that you gotta work with a test
a number of times to get a feel
for how your going to grade that.
- And then walking time, oh, heels apart or heels to
- And this one, you have to be in line
in the sagittal plane, We call it right in line
with whats right in front of them or directly behind them.
And the distance right here is what we're talking about.
And you get the maximum number of points on your
walking and your heels almost touch each other.
That's good. That's normal gait pattern.
- Yeah.
- So show, show the wide stance.
- Yeah. Somewhat bad balance.
They try to widen their base.
So they're not going to fall.
So they're going like this.
You see someone walking like this, you know
they have bad, but often bad balance too.
- Right.
- Trying to get.
So these are things you can look at, you know
your mother or father, if they're doing some things
like taking a step and walking with a wide base
that means their balanced probably isn't that good.
- Have their arms...
- Can they turn around again,
Be very careful if you do this with anybody, I mean
- Right, it's good to have two people you don't want have
cause an accident, just doing one of these things,
- But I would use it more on an observational basis.
You're seeing your parent do these things.
- Exactly.
- Then you may want to have them go in and
and get tested and make sure
that there's nothing you can do that there's not
something you can do to help them have better bounds.
- Sure.
- Or also, you're just going to have to make sure
that they maybe have a fall alert or some, you know
some type of alert system so that
if they do fall that...
- they're not there all night long.
- Yeah, exactly. So...
- So once again, Mary Tinetti, she did excellent job.
- Yeah. Thanks a lot, Mary.
- And what else can we say, Bob?
- Well, we can fix just about anything
but we can't fix a...
- A broken heart, but we're going to work on it.
- Yeah. We're going to try to get that down.
- A couple of those classes.
I've been looking that up online, Bob.
- Good for you.
- Some of those studies.