Two Fall Prevention Fundamentals Your Patients Need ASAP

As your patients age, a natural reduction in equilibrium can put them at risk for a fall. As a matter of fact, studies show that the older they get, the more the risk increases.

“Falling is the leading cause of injury-related deaths in older adults. For those of ages 70–79 years, 27.7% of injury-related deaths are attributable to falling. This proportion increases to 46.4 and 64.8% for those of ages 80–89 years and 90–99 years, respectively. Gryfe et al. reported that 45% of adults over 65 years of age will experience at least one fall per year and many of these individuals will fall repeatedly.” ₁

As a hands-on healthcare professional, you should be equipped with the necessary knowledge and resources to keep older adults away from a damaging fall. For this week’s installment of the Injury Management Series, we’ll walk through the contributing factors to fall risk, as well as the most effective (and safe!) ways to approach prevention.

Dr. Michael Rogers, chairman of Human Performance Studies at Wichita State University, has spent years researching fall prevention methodologies. Before treating a patient, he suggests compiling a total patient history to assess the patient’s risk and reduce the physical, mental and environmental risk factors as much as possible. Here are 23 contributors that Dr. Rogers and his colleagues have outlined as critical components to falls in older adults:₁

1. Reduced visual acuity, depth perception, and peripheral vision Vestibular impairment
2. Reduced ability to sense touch and vibration
3. Reduced static and dynamic balance
4. Reduced walking speed
5. Poor mobility and gait disorders
6. Reduced strength of the lower extremities
7. Reduced reaction time
8. Acute illness
9. Chronic disease that affects sensory, neurological, cognitive and muscular functions
10. Cognitive impairment
11. Polypharmacy, especially the use of four or more prescription drugs



External contributors to fall risk



12. Inadequate lighting brightness and placement of switches and fixtures
13. Lack of handrails on stairs inside and outside of home
14. Cords and wires on floor
15. Lack of grab bars around toilet and bathtub
16. Lack of non-slip strips on bathtub floor
17. Toilet seat that is too low
18. Polished or waxed floors
19. Furniture that is too low or is not sturdy
20. Throw rugs that are not secured
21. Sidewalk cracks and ridges
22. Ice and snow
23. Prosthetic and cane or walker use

For an evidence-based list of methods to assess and improve the physical parameters associated with fall risk in older adults, read the full article here.

After analyzing your patient’s full risk profile, you’ll be better prepared to create a personalized plan of attack. Make sure you capitalize on the following vital fundamentals when building a fall prevention program or protocol!

According to the American Physical Therapy Association (APTA) Section of Neurology, good balance depends on “correct sensory information from your eyes (visual system), muscles, tendons, and joints (proprioceptive input), and the balance organs in the inner ear (vestibular system).”₂ As a hands-on healthcare professional, most of your rehabilitative and/or. preventative work will culminate within the mechanics of proprioceptive input to enhance the motor output of your patient.

Because balance training has been proven to help older adults improve dynamic balance ability and potentially reduce risk for falls,₃ stability exercises are a legendary staple in fall prevention programs. However, as Dr. Rogers points out, stability training can potentially be dangerous and contradictory in nature. “What we’re trying to do is challenge the systems that control balance, which means we’re putting people into a position where there is a heightened risk for falls while doing so,” he said. Basically, to keep them from falling, we need to put them in scenarios where they are more likely to fall.

When training this vulnerable population, prescribing balance exercises that are safe and appropriate for the individual patient is imperative; stability training, like any other rehabilitative or preventative effort, is not a one-size-fits-all solution.

1. Understand that, just because you have special equipment to train balance, doesn’t mean you should use it.

Balance training products like the TheraBand Stability Trainer or TheraBand Pro-Series Exercise ball are a great way to improve stability. In fact, one study suggests that challenging the physiological systems involved in balance control while on the unstable support surface improves both static and dynamic balance in older adults and may reduce the risk for falling.₄ But, just because you can put your patients in more compromising solutions doesn’t mean that you should.

The key to preventing a fall during balance exercise is to not challenge them to the point of discomfort or unsteadiness. Like any other exercise, gradually increase the challenge and let the body adapt at its own pace. Thankfully, there are many options when it comes to stability training. Exercises can be done:

• On the solid ground or a number of more challenging surfaces
• On one two legs, one leg or in a half-kneeling position
• With eyes open or closed

For evidence-based guidelines on how to best prescribe balance exercises, check out the progression protocol we outlined in our Ankle Sprain Injury Management Series.

2. Stability training should be done around a steady object.

In the midst of a balance exercise, patients commonly sway, lose their balance and need an object to catch themselves on and keep them upright. Make sure your patient always has a solid surface in front of them when performing any level of stability training, such as a table or a counter.

The second component of fall prevention protocol is strength training, which commonly goes hand-in-hand with balance training. Exercise with low-cost devices such as elastic bands and rocker boards has been shown to improve balance, endurance, strength, gait and function in chronically impaired, fall-prone elderly persons.₅ Here are three balance-specific areas of the body to focus on when conducting strengthening exercises:

A study concluded that a twelve-week hip-focused exercise program effectively improved dynamic balance compared to a control group. In particular, patients who engaged in the exercise plan improved their reaction to perturbation, which is a primary cause of falls. Finally, the study concluded that medial-lateral stabilization improvement may help reduce lateral falls leading to hip fracture, but more research is needed.₆

After a twelve week program focused on ankle muscle strength and balance improvement, elderly patients increased one-leg standing time and tended to decrease the frequency of falls.₇

Another study proved that a low-cost strength training of dorsi-and plantar flexors improved strength, balance and functional mobility in institutionalized elderly people. Also, the improvement in plantar flexor strength was attributed to observed balance improvements.₈

However, don’t get too hung up on training specific muscles and ligaments. Focusing on full-body strength can help improve the musculoskeletal system as a whole, which in turn decreases the likelihood of falls! In a recent study, older women were randomly assigned to an exercise group (multi-purpose program focused on exercise intensity) or a wellness group (wellness program focused on low-intensity, low-frequency exercising). Compared to the wellness group, the women in the exercise group significantly improved bone mineral density and fall risk. As an added benefit, they were able to achieve these results with no increase in direct costs.₉

Dr. Roger’s expertise in protecting the elderly is unparalleled.

Check out which exercises he recommends every professional try out with their patients who are at risk for falls!

Resources:

• 1. Rogers M. E. et al. 2003. Methods to assess and improve the physical parameters associated with fall risk in older adults Preventive Medicine 36(3):255-264
• 2.http://www.neuropt.org/docs/vsig-english-pt-fact-sheets/how-does-the-balance-system-work.pdf?sfvrsn=2
• 3. Narita M et al. 2015. Effects of customized balance exercises on older women whose balance ability has deteriorated with age. J Women Aging. 27(3):237-50.
• 4. Rogers M. E. et al 2001. Training to reduce postural sway and increase functional reach in the elderly Journal of Occupational Rehabilitation 11(4):291-298
• 5. Rubenstein L. Z. et al 2000. Effects of a group exercise program on strength, mobility, and falls among fall-prone elderly men Journal of Gerontology: Medical Science 55A(6):M317-M321
• 6. Boeer J, et al. 2010. Effects of a sensory-motor exercise program for older adults with osteoarthritis or prosthesis of the hip using measurements made by the Posturomed oscillatory platform. J Geriatric Phys Ther. 33(1):10-15
• 7. Kim B et al. 2006. The Effect of Fall Prevention Exercise Program for the Elderly (Abstract)Medicine & Science in Sports & Exercise 38(5) Supplement May:S443
• 8. Ribeiro F et al 2009 . Impact of low cost strength training of dorsi- and plantar flexors on balance and functional mobility in institutionalized elderly people Geriatr Gerontol Int. Mar;9(1):75-80
• 9. Kemmler W et al. 2010. Exercise effects on bone mineral density, falls, coronary risk factors, and health care costs in older women: the randomized controlled senior fitness and prevention (SEFIP) study. Arch Intern Med. 170(2):179-85.