Dynamic Arc Training Module

This course will outline the utilization and optimization of the Dynamic Arc functional balance assessment in your practice

Introducing the Dynamic Arc! Software Installation, Device Assembly, Safety Information

After this introduction, you will be able to understand the specific role the Dynamic Arc fulfills in your facility

The Dynamic Arc is the premier functional balance system utilized in healthcare today. Whether for balance screening, assessment or rehabilitation/treatment, the Dynamic Arc provides an objective platform to provide optimal care to your patients and residents.

This brief video will give you insight to the specific role that the Dynamic Arc will have in the provision of your services.

 

True or False on the general abilities of the Dynamic Arc

  • The Dynamic Arc: Barnett Balance Assessment is a descriptive and objective functional balance assessment
  • The Dynamic Arc: Barnett Balance Assessment collects objective data on functional balance performance that can be directly translated to a patient's ability to perform functional tasks
  • The Dynamic Arc: Barnett Balance Assessment lacks the ability to quantify a patient's progression under your care
  • The data provided by the Dynamic Arc: Barnett Balance Assessment will reinforce your documentation by objectively establishing medical necessity, quantifying patient gains as a result of intervention, and determine outcomes

Software Installation

If your product came with the included CD-Rom, insert the disc into your laptop at this time. Click on the disc drive to open the software then complete the following steps:

TO LOAD THE SOFTWARE ONTO YOUR COMPUTER:

  1. Open the software and drag the two folders titled "Software-BBA" and "Read Me Files" onto your desktop
  2. Once the software has successfully downloaded onto your computer, open the "Read Me Files" folder and explore the various documents/templates for your use. Included in this file are several references that our clinical specialists have assembled for ease of use, documentation shortcuts, and verbiage for documentation with other items.
  3. Once you have read the files in the "Read Me" folder, open the "Software-BBA" folder.
    1. Double-Click on the "setup" icon and run the software setup.
    2. Once setup is completed, you can then click the icon labeled "Barnett Balance Assessment". The program will load and display the data collection sheet upon opening.

WORKING WITH THE BARNETT BALANCE ASSESSMENT PROGRAM:

The program itself does not store patient information but rather acts as a collection and scoring platform. In the program there is 2 tabs at the top; the "Worksheet" and the "Results". You will input all the appropriate data into the worksheet, and then click the results tab upon completion for normative comparisons and raw scores. Once all data is entered and results tallied, you can either print the score sheets to your local or network-based printer or save the image as a .tiff to your desktop to load into your EMR. The printed score sheets (there will be 2 in total) can also be scanned and uploaded to your EMR should you choose that option as well.

Make sure you maintain all files in the designated folders or the program will not work correctly.

Device Assembly

The Dynamic Arc has 2 components for assembly, the base/column and the arc itself. To assemble, raise the column up and fasten screw to secure. Make sure that the screw is tight to prevent sway in the column itself.

Then, place the arc on to the column with the post placed in the hole on top. Make sure the arc is properly aligned with the etching on the moving mechanism placed in the front side of the column. Also, make sure that the screw on the underside of the Dynamic Arc rests in the groove that is on the collar of the column.

 

Mechanisms of Dynamic Arc

The moving parts for the Dynamic Arc are labeled in the image below. Click on a hotspot to highlight movable part:

Safety Information

  1. The Dynamic Arc is a medical instrument that should be utilized ONLY by trained and licensed medical professionals who have successfully completed and passed associated training module
     
  2. The Dynamic Arc is a dynamic balance device. Proper safety must always take priority over scoring. ALWAYS utilize a gait belt during assessment and NEVER assess a patient who is a danger to harm themselves during usage. Use clinical judgement to maintain safety, associated precautions (hip precautions, spine precautions, etc) to ensure accurate scoring and no harm to patient.
     
  3. The Dynamic Arc is NOT DESIGNED to hold weight, as an important safety mechanism is for the instrument to fall out of the way should it be placed in a hazardous position. ONLY maintain <5lbs of weight total on the Dynamic Arc to ensure compliance.
     
  4. The Dynamic Arc is protected with anti-microbial coating however is safe to properly sanitize prior to/following use. Maintain sanitary conditions when utilizing this and all equipment
     
  5. When moving the Dynamic Arc through the mechanisms, make sure that the patient's and administrator's hands are clear from moving parts to prevent injury

CPT Coding and ICD-10

Samples of Applicable ICD 10 Coding to Justify Assessment:

Z91.81 History of Falling

R26.9 Abnormalities of gait

M62.81 Muscle Weakness

R26.2 Difficulty in Walking

R26.81 Unsteadiness on Feet

R29.6 Repeated Falls

Appropriate CPT Coding to Report:

97750-Physical Performance Test with Written Report (Most often utilized and most appropriate)

  • Time-based code (reported in 15 minute units) utilized by MD's, DO's, DPM's, DC's, NP's, PA's,  PT/OT's
  • MUST include written report in patient's medical record. See CMS guidelines for further definition
  • CANNOT be reported on same day as PT/OT Evaluation or PT/OT Re-Evaluation
  • Frequency is typically every progress reporting period 10-14 days or when deemed medically necessary

*Other Physical Medicine/Physical and Occupational Therapy Codes can be appropriate if nature of assessment/activity is more applicable to another coding category.

Setting up the Dynamic Arc

Setting up the Dynamic Arc for assessment video

 

Setting up walk through

Setting up the Dynamic Arc involves 2 variables based on the patient's specific body structure: the height of the Dynamic Arc and the distance of the Dynamic Arc. To determine these positions, follow these steps.

1. Place the 3-inch magnetic clip on the center of the horizontal arm over the Dynamic Arc logo

2. Have the patient step toward the t-shaped lines on the floor with both feet on either side of the vertical line and with toes touching the front line. Instruct the patient to stand comfortably with feet shoulder-width apart

3. The patient will bring his/her arms into 90 degrees of flexion, with hands clasped together. Raise the Dynamic Arc to meet the height of the patient's arms. Bring the Dynamic Arc toward the patient's extended arms and have the patient touch the marker with their 3rd digit/middle fingers.

Once the Dynamic Arc is properly positioned, record the vertical setting (engraved on the column of the Dynamic Arc) and the device distance (bring tape measure attached to hook on bottom of the Dynamic Arc to FRONT LINE by patient's feet) on the score sheet.

Locate area on score sheet to record "Device Distance" and "Vertical Setting"

Re-Test Measures

When re-testing patients for follow-up measurements, utilize the same "Device Distance" and "Vertical Setting" numbers to ensure consistency.

What is the first step when setting up the Dynamic Arc for assessment?

  • Bring shoulders to 90 degrees of flexion
  • Have patient step up to front of the line with toes touching the line itself
  • Touch marker with 3rd digit (middle finger) with extended hand

What is the 2nd step in setting up the Dynamic Arc for assessment?

  • Have patient bring arms into 90 degrees of shoulder flexion with elbows/fingers extended and hands clasped together
  • Touch the magnetic marker with the 3rd digit (middle finger)
  • Move the Dynamic Arc to the patient's extended hands

Following the patient being properly positioned, what is the 3rd step in setting up the Dynamic Arc?

  • Have patient touch magnetic marker with outstretched 3rd digits (middle fingers)
  • Raise the vertical column of the Dynamic Arc to meet the height of the patient's positioned upper extremities
  • Measure the distance of the Dynamic Arc using provided tape measure

What is the final step in setting up the Dynamic Arc?

  • Bring the Dynamic Arc toward the patient's extended arms and touch the magnetic marker. Take hooked tape measure on bottom of Dynamic Arc and measure distance to tape at patient's feet
  • Raise the Dynamic Arc up into the vertical position
  • Have the patient step toward the marked lines on the floor with toes touching the front line

Administering the Assessment

Once set up is complete, you are ready to administer the assessment and collect patient performance data!

 

Key components in administration

HAND PLACEMENT ON THE MARKERS:

Make sure that the subject grasps the markers around the tape throughout the assessment. If the subject grasps the marker on areas other than the tape, the assessment results will be invalid

FOOT PLACEMENT THROUGHOUT THE ASSESSMENT:

With the subject's feet positioned properly touching the tape, the subject will be instructed to move through the assessment. The subject MUST maintain both feet on the ground at all times during the movements, however the subject's heel may rise as long as the ball of the subject's foot remains on the floor.

OK FOOT ACTION

OK FOOT ACTION as Ball of Foot Remains on Floor

Positions of the Dynamic Arc during assessment

Actions

Each position (Horizontal, Ascending Left to Right, etc) has 4 actions. Each group of actions involves 2 with the Left hand and 2 with the Right.

ASCENDING REACH AND OUTWARD REACH COLUMNS

Each eyelet on the horizontal arm of the Dynamic Arc is labeled A, B, C, or D. Each action will involve either the Left hand or the Right hand placing the white markers in order (either A, B, C then D or D, C, B, then A).

BALANCE ARC COLUMN

The Arc itself has been fixed with 3 rings. Using the directed Left hand or Right hand, the subject will move each of the 3 rings from one end of the arc to the other (either Left to Right side or Right to Left side)

Scoring Protocol

SCORING PROTOCOL

A marker is considered successfully placed if the patient can lean, place marker, and then return to center. If a patient loses balance in the process, states that they cannot reach/place marker, or is unable to return to center following placement, the marker is considered missed.

ASCENDING REACH AND OUTWARD REACH

Each action is scored either 0, 1, 2, 3 or 4. The score is determined whether the subject can successfully place the markers.

EXAMPLE:
RIGHT HAND: A, B, C, D
Pt successfully places marker on eyelets A, B, C, and D. This determines a score of 4

 

BALANCE ARC

Each action in the Balance Arc column involves moving the rings one at a time with either the Right hand or Left hand from one side of the arc to the other. Each action is scored either 0, 1, 2, or 3.

EXAMPLE:
LEFT HAND Right to Left:Pt successfully moves the rings from Right side to Left side 3 successful times. This determines a score of 3
 

How to score missed markers

 

Missed marker protocol for Ascending Reach and Outward Reach

If a patient misses a marker, give them one more opportunity to place successfully. IF the patient is able to successfully place that marker the 2nd time, continue to the next marker. IF the patient is unable to place the 2nd time or states that they are unable/unwilling to attempt the placement, count that marker as missed and the action is over (in other words, do not attempt the remaining eyelets in that action).

EXAMPLE:

Patient 1 uses RIGHT hand to place markers successfully on eyelet A and B. Eyelet C is missed the first time, however the patient is able to successfully place marker and return to center on 2nd attempt. The patient then moves on to eyelet D and successfully places that marker. THIS RECORDS A SCORE OF 4.

Patient 2 uses RIGHT hand to place markers successfully on eyelet D, however misses eyelet C twice. THIS RECORDS A SCORE OF 1 and the action is over. The patient does not attempt to place on eyelets B or A because the action is ceased following the 2 misses.

Patient 3 uses LEFT hand to place markers successfully on eyelet A however misses eyelet B once. The patient is given a second chance and places the marker on eyelet B successfully the 2nd time. The patient then attempts eyelet C however misses the first time. On the 2nd attempt, the patient is successful of placing the marker. The patient then misses eyelet D twice on the next attempt. THIS RECORDS A SCORE OF 3.

Patient 4 uses LEFT hand to attempt to place marker on eyelet D however misses the first attempt. The patient then states that they do not want to attempt a second attempt due to loss of balance. THIS RECORDS A SCORE OF 0.

A patient uses his RIGHT hand to place marker on eyelet A, B, C however misses eyelet D twice. What is the recorded score?

  • 0
  • 1
  • 2
  • 3
  • 4

A patient places marker on eyelet A and B however misses the first attempt at marker C. What happens next?

  • Give the patient one additional opportunity to attempt to place marker on eyelet C. If she/he is successful, continue to attempt eyelet D
  • Cease 2nd attempt on C and record a score of 2
  • Continue to D and record a miss on C for a score of 3

A patient states that they are not confident to place a marker on the first eyelet D. What happens next?

  • Have the patient attempt the placement anyway
  • Skip marker D and proceed on to C, B, then A. Record score.
  • Record a score of 0. Do not attempt the next markers (C, B and A) and move on to the next Action

Choose all circumstances which qualify as a "miss" or a loss of balance

  • Patient lifts one foot completely off the ground, such as taking a step
  • The patient lifts the heel of one foot off the ground but maintains ball of foot throughout movement
  • Patient states that they cannot reach/place marker
  • Patient experiences a loss of balance when attempting to place marker on eyelet
  • Patient reaches out and places marker on eyelet however is unable to return to center/base of support
  • Patient reaches out and struggles to place marker on eyelet however finally does. The patient is able to return to base of support and maintained foot contact with floor throughout movement

Assessment Analysis

So What Does it Mean???

By now, you have seen the complete assessment in action and understand the method of performance. So what does the data mean?

On the score sheet under the "Results" tab, you will find that the patient's score is compared to population norms. If a deficit is detected, it means that the patient exhibits an impairment in maintaining balance when performing specific functional movement patterns utilized in everyday life. Some movement patterns are not severe in nature and can be addressed in a lesser restrictive environment or through compensatory means. In some findings, you will see that the patient's functional balance ability is severely compromised and the necessity of immediate intervention is greater in order to prevent or mitigate the risk of a catastrophic fall.

In any case, if a deficit is detected, this assessment provides objective justification to assist in establishing medical necessity for intervention. It is up to the licensed clinician to utilize their personal skill set to determine the type of intervention, the location of care, and the frequency/urgency on which to seek assistance.

Analyzing the Data with Focus on Impairment Percentages

The Barnett Balance Assessment is norm-referenced which compares a patient's score to researched norm populations. By utilizing this method, we are able to determine overall impairment percentage in the 10 independent categories listed.

Impairment

                      Impact on Functional Levels

0%

Pt is performing at functional level appropriate for their age (INDEPENDENT on this measure)

1-19%

Pt is performing at modified-independent level of function and may require additional time or the use of assistive devices to perform functional tasks (MI)

20-39%

Pt is performing at functional level which may require potential assistance (less than 25%)/supervision in close proximity to maintain safety (SBA/CGA)

40-59%

Pt is performing at a functional level which may require greater than 25% but less than 50% assistance in functional tasks to maintain safety (Min A)

60-79%

Pt is performing at a functional level which may require greater than 50% but less than 75% assistance in functional tasks to maintain safety (Mod A)

80-99%

Pt is performing at a functional level which may require greater than 75% but less than 100% assistance in functional tasks to maintain safety (Max A)

100%

Pt is DEPENDENT on others to complete functional tasks to maintain safety (TD, TD+)

Categories of impairment and impact on functional performance

Category

Analysis

Sample Functional Activity

Total Assessment Score

The overall “big picture” on the patient’s functional measure.

  • All activities listed

Ascending Reach

Ability of patient to maintain balance and stability when reaching upward/downward.

  • Retrieving/placing an item off the floor or above head into a cupboard
  • Functional interaction in the frontal plane involving bending in the core

Outward Reach

Ability of patient to maintain balance and stability when reaching outward at Min, Mod and Max range.

  • Reaching for/placing objects across a tabletop or into a closet
  • Functional activity interactions in the frontal plane

Balance Arc

Ability of a patient to maintain balance and stability when functionally shifting weight from side-to-side

  • Transfers during functional activities such as toilet transfers or transfers to wheelchair on bilateral sides
  • Functional activity interactions in the sagittal plane

Left Side

Ability of a patient to maintain balance and stability when performing functional activities on the LEFT side of the body while bearing weight on the LEFT lower extremity

  • ADL activities on the LEFT side of the body with weight distributed primarily on the LEFT lower extremity

Left Side with Rotation

Ability of a patient to maintain balance and stability when performing functional activities on the LEFT side of the body using the RIGHT upper extremity facilitating trunk rotation during movements while bearing weight on the LEFT lower extremity

  • ADL activities on the LEFT side of the body emphasizing trunk rotation (core movement) during task with weight distributed primarily on the LEFT lower extremity

Right Side

Ability of a patient to maintain balance and stability when performing functional activities on the RIGHT side of the body while bearing weight on the RIGHT lower extremity

  • ADL activities on the RIGHT side of the body with weight distributed primarily on the RIGHT lower extremity

Right Side with Rotation

Ability of a patient to maintain balance and stability when performing functional activities on the RIGHT side of the body using the LEFT upper extremity facilitating trunk rotation during movements while bearing weight on the RIGHT lower extremity

  • ADL activities on the RIGHT side of the body emphasizing trunk rotation (core movement) during task with weight distributed primarily on the RIGHT lower extremity

Shift from Left to Right

Ability of the patient to shift weight laterally from standing/neutral to the RIGHT lower extremity using the LEFT upper extremity to steer movement patterns

  • Transitional movements including transfers to the RIGHT side

 

Shift from Right to Left

Ability of the patient to shift weight laterally from standing/neutral to the LEFT lower extremity using the RIGHT upper extremity to steer movement patterns

  • Transitional movements including transfers to the LEFT side

 

Analysis Example for Evaluation

"The objective measurement in the BBA has identified that the medical condition (ICD-10: R26.2-Difficulty in Walking) has limited the functional independence, physical ability, and quality of life of the patient. It is reasonable and necessary for this patient to receive skilled services to increase functional independence and improve functional capability to facilitate a return to maximum performance level. At this time the patient has specific and significant impairment between 40-59% in functional balance on the RIGHT SIDE and on the RIGHT SIDE DURING TRUNK ROTATION indicating the requirement of Minimal Physical Assistance to maintain safety when performing functional tasks".

Analysis Example for Progression Following Intervention

"As a result of medical management and intervention, the patient has increased their overall score in the BBA from 127 to 142 indicating that the plan of treatment has facilitated an objective gain of 10.1% from January 1 to January 8. Patient's current score indicates an impairment of 1-19% in the overall score with evidence that patient has ability to continue to improve with skilled care and return to prior level of function."

Documentation Shortcuts and G-Code Modifiers

The software disc contains scripted examples on clinical analysis narratives for all disciplines pertaining to documentation of results. Use these examples as a building block to format analysis for your EMR and patient records.

For applicable patients, the results page showcases the appropriate G-Code modifier that can be attached to the reporting component. Typically, the G-Code that is utilized with this assessment is in the G8981-3 grouping: Changing and Maintaining Body Position. An example of a commonly utilized physician EMR is referenced below.

With the G-Code in place, reference the "Results" section of the assessment and identify the GREATEST IMPAIRMENT PERCENTAGE to determine the appropriate modifier:
For additional information on G-Codes and Modifiers for Medicare Part B, reference the following link:

www.CMS.gov

SCENARIO ANALYSIS WITH QUIZ

Examine the following results and provide appropriate answers to multiple-choice prompts:

Choose all answers which would be relevant to this assessment result

  • The Pt currently presents with a remarkable impairment in functional balance ability with primary deficits identified in maintaining balance in Outward Reaching tasks, and tasks when reaching on the Right Side, both with 20-39% impairment.
  • Total Assessment score indicates and overall impairment between 1-19%.
  • The Pt has c/o increased pain when weight shifting from Right to Left Side
  • The Pt has stated that he "feels ok when moving around"
  • The Pt has a significant impairment which warrants intervention in order to restore functional independence and reduce the risk of experiencing a catastrophic fall during functional movements
  • The Right Side impairment is consistent with the medical diagnosis of a RIGHT TKA
  • The Pt stated that he is "experiencing increased pain in the RIGHT knee" which may be cause of decreased balance ability and independence during functional movement patterns. Pain management to affected area is indicated to potentially improve balance.
  • Plan of treatment to include evidence-based treatment approaches tied to medical diagnosis with re-testing to determine improvement in functional balance and independence

Peripheral Nerve Decompression Patient - for Physician

Read the following results and answer the questions for analysis:

Choose all answers that would apply for analyzing this data

  • Pt has made no gains measured on this assessment from previous analysis
  • Pt has demonstrated a gain of 39 points from previous assessment, indicating a gain in functional balance ability
  • Pt currently presents with minimal impairment (1-19%) in functional balance on the LEFT Side
  • Pt has demonstrated gains as a result of skilled medical intervention and is appropriate to continue with current plan of treatment based on the measured results
  • When compared to baseline score, this measure indicates that the patient has made significant gains in functional balance ability as a result of surgical and rehabilitative intervention
  • The patient should be assessed in the next 2 weeks to determine outcomes of procedure and quantify current functional ability in order to facilitate to the most appropriate level of care

Run Through of Complete Assessment for Reference

Assessment Run Through

 

Final Proficiency Exam

Select the image that shows the Dynamic Arc in the "Ascending from Right to Left" position

The patient is able to place markers on eyelets A, B, and C however misses D one time. What should be done next?

  • Stop the action and score 3
  • Give the patient another opportunity. If he/she successfully places the marker on D, record a score of 4. If unsuccessful a 2nd time, record a score of 3
  • Ask the patient if he/she is afraid of falling

Answer True or False

  • The Dynamic Arc is designed to identify functional balance impairments and compare them to population norms

The Dynamic Arc has been utilized by the following healthcare professionals/settings

  • Senior Communities (ALF, ILF, Nursing Home, Group Home)
  • Physician/Surgeon Practicies
  • Home Health Companies
  • PT/OT Practices

Choose the best answer: The Dynamic Arc is best utilized when you want to capture what type of patient performance data?

  • Overall balance ability performing simple movements with the lower extremities
  • A patient's ability to reach up and down utilizing the bilateral upper extremities
  • A patient's ability to maintain balance when performing movements similar to those utilized in everyday life, using the upper extremities to drive lower extremity weight shifting

Match the Balance Category with Activity Experiencing Functional Impairment

  • 1-19% Impairment on Right Side
    Slight impairment maintaining balance when performing functional tasks on the Right Side of the body
  • 20-39% Impairment Weight Shift Left to Right
    Significant Impairment when weight shifting from the Left leg to the Right leg during functional activities
  • 40-59% Impairment Ascending Reach
    Functional activities when reaching upward or downward require MINIMAL PHYSICAL ASSISTANCE to maintain balance and safety
  • 1-19% Impairment Total Score
    The patient has a slight overall functional balance impairment when performing ADLs
  • 40-59% Impairment Left Side with Rotation
    The patient requires MINIMAL PHYSICAL ASSISTANCE to maintain balance when performing functional movements on the Left Side of the body while rotating the trunk
  • 20-39% Impairment Balance Arc
    Patient requires stand-by assistance to maintain safety and balance when weight shifting from side-to-side (both Left to Right and Right to Left)
  • 20-39% Impairment Outward Reach
    Patient requires stand-by assistance to maintain safety and balance when performing functional activities that require reaching outward in front of the body

Place the "Set-Up" protocol in order

  • First Step
    Place magnetic marker on horizontal arm of Dynamic Arc covering the logo
  • Second Step
    Have patient step up to "T" shape on either tape or mat on floor. Have patient stand in a comfortable position with feet on either side of perpendicular line separating Left side and Right side with toes touching the front line.
  • Third Step
    Have patient bring shoulders into 90 degrees of flexion with hands together. Raise height of Dynamic Arc to height of patient's outstretched hands and move Dynamic Arc toward patient until magnetic marker touches patient's two middle fingers.
  • Fourth Step
    Check to make sure that positioning is correct and that the Dynamic Arc is centered in front of patient
  • Final Step
    Locate "Vertical Setting" on column of Dynamic Arc and record. Bring Measuring Tape fastened to Dynamic Arc's base hook toward tape and measure the "Device Distance" from Instrument to center of "T" shape on floor. Record "Device Distance" on scoresheet.

Answer True or False

  • It is necessary to achieve accurate progression to maintain the same "Device Distance" and "Vertical Settings" when re-testing patients

Choose the MOST APPROPRIATE CPT Code when reporting the Dynamic Arc's Functional Balance Assessment

  • 97710 Therapeutic Exercise
  • 97750 Physical Performance Test with Written Report
  • 97712 Neuro Re Ed
  • 97535 Self Care Tasks

Identify an appropriate ICD-10 Code that would justify the need for the Dynamic Arc Functional Balance Assessment

Examine this Medicare Part B patient's result. If utilizing G-Code 8981 "Changing and Maintaining Body Position" for evaluation, what would the appropriate modifier be? (answer on next page)

Identify modifier from previous page.

  • CN
  • CI
  • CK
  • CM
  • CH

Contact Information

Contact Information

Should you have additional questions, please feel free to contact our offices to speak with a clinical specialist for support or email our company at the following address:

Office: 248-792-6301
Email: [email protected]
Physical Address: 280 North Old Woodward Ave, Ste 107 Birmingham MI, 48009

We thank you for your attention and look forward to working with you!