Understanding Balance
and
Falls Prevention
Dr. absar ullah khan
1
What is fall?
Fall defined as “an unintentional loss of balance that
leads to failure of postural stability”.
or
Sudden and unexpected change in position which
usually results in handling on the floor”
Epidemiology of falls in elderly
Definitions
Classifications
Ageing
Incidence
Epidemiology of falls in elderly
Classifications:
Falls Fallers
Intrinsic Non-fallers
Trigger
Extrinsic Once-only fallers
Recurrent fallers
Consequence Injurious
Non-injurious
Epidemiology of falls in elderly
Incidence:
Accidents are the 5th leading cause of death in older
adults
Falls account for 2/3 of these accidental deaths
1/3 of adults over 65 living in the community fall at
least once a year
This rises to ½ of adults over age 80 5% of these falls
result in a fracture or hospitalization
Mobility abnormalities affect 20-40% of adults over
65 and 40-50% of adults over age 85
Epidemiology of falls in elderly
Incidence:
Mortality Of those who are hospitalized, ~50% will not be alive a
year later
Falls constitute 2/3rd of deaths associated with unintentional
injuries
In 2000 traumatic brain injury (TBI) accounted for 46% of fatal
falls.
Cost Fall-related injuries are among the most expensive health
conditions
In 2000 $179 million were spent on fatal falls and $19 billion
were spent on injuries from non-fatal falls
Epidemiology of falls in elderly
Incidence:
Location Most falls occur outdoors
Women are more likely to report indoor falls
Indoor falls are associated with frailty
Outdoor falls are associated with compromised health status
in more active elderly
Epidemiology of falls in elderly
Incidence:
The rate of falls and their associated complications are ~ twice over the age
of 75 years.
10-25% falls induce fractures in this population
Hip fractures are more common after the age of 75 years
Those ≥75 years of age are more likely to report indoor falls
Incidence is higher in certain populations (e.g. institutionalized elderly,
diabetics, Parkinson’s disease, post-stroke etc.)
Balance and Falls Are Related
www.continuumcare.com
www.healthycellsmagazine.com
Fall Facts
1 out of 3 over age of 65 fall, <50% tell doctor
1 out of 5 has serious injury, 12.5 mil in ER
>700,000 hospitalized
34 billion in direct medical costs www.cdc.gov
www.sciencealert.com
3 Major Problem Areas
of the Home:
Outside Steps To The Entrance
Inside Stairs To A Second Floor
Unsafe Bathrooms Source: HUD (2001)
Other Alternatives to Entrance
with Outside Steps
Ramps
Earth Berms/Walkways
Lifts
Zero Step entrance
Other Strategies for Getting Upstairs
Chair lift
Elevator
Relocate rooms to main
floor
Strategies for Bathing
Bath bench/chair
Bath lift
Grab bars
Visual contrast
Non slip surface
Hand held showerhead
Shower/wet room
Curbless shower
Fractures
3% of all falls cause fractures.
Approx. 95% of hip fractures in older people aged
over 65 years are the result of a fall
People who have a hip facture are 5 ~20% more likely
to die in the first year following the injury than any
other reason in the same age groups
Common Types of Fractures
Forearm (Wrist) Fracture
Spine Fracture
Hip Fracture (pelvis, hip, femur)
Ankle Fracture
Upper arm, forearms, hand
Fear of Falling
Loss of self confidence
Decrease of physical activity level and quality of life
Fear of not being able to get up after a fall
Fear of Falling
Activity restriction Poor perceived health
Social withdrawal Reduced strength
Poor balance
Increased disability Increased fall risk
Reduced independence
Poor quality of life
Extrinsic or Environmental Factors
Polypharmacy – four or more prescription medications
combination
Home hazards
Clutter, or loose rugs
Poor lighting on stairs and hallways
Lack of bathroom safety, e.g. grab bars in bathtub
Footwear
Busy street or elevated walkways
Cognitive impairment or dementia
Chronic illness
- Parkinson disease, visual difficulties, stroke,
hypertension, or urinary incontinence
Psychoactive medication
- tranquilizers or antidepressants
Previous falls
Heavy drinking
Extrinsic or Environmental Factors
Polypharmacy – four or more prescription medications
combination
Home hazards
Clutter, or loose rugs
Poor lighting on stairs and hallways
Lack of bathroom safety, e.g. grab bars in bathtub
Footwear
Busy street or elevated walkways
Mechanisms of Fall
Contributing
Intrinsic : factors Extrinsic :
Aging, poor balance Home hazards
Occurrence of falls
No injuries
Fall Outcomes
Soft tissues Loss of Disability,
Fractures
injures, Confidence reduced
trauma quality of life
INTRINSIC FALL RISK
FACTORS
AGE-RELATED HEALTH
CHANGES CONDITION
RELATED
Somatosensory Diabetic/Idiopathic
neuropathy
Decreased light touch Spinal stenosis
Decreased proprioception Stroke
Decreased two-point Mutiple sclerosis
discrimination
Decreased vibration sense
Decreased muscle spindle
activity
INTRINSIC FALL RISK
FACTORS
AGE-RELATED HEALTH
CHANGES CONDITION
Visual RELATED
Decreased visual acuity Cataracts
Decreased contrast Macular degeneration
sensitivity
Decreased depth Glaucoma
perception
Diabetic retinopathy
Stroke
Use of progressive,
bifocal,
or trifocal corrective
lenses
INTRINSIC FALL RISK
FACTORS
AGE-RELATED HEALTH
CHANGES CONDITION
Vestibular RELATED
Decreased vestibular hair Benign paroxysmal
cells positional vertigo
Decreased vestibular Unilateral vestibular
nerve fibers hypofunction
Meniere disease
Bilateral vestibular
hypofunction
INTRINSIC FALL RISK
FACTORS
AGE-RELATED HEALTH
CHANGES CONDITION
CNS RELATED
Decreased coordination Parkinson’s disease
Stroke
Cerebellar atrophy
INTRINSIC FALL RISK
FACTORS
AGE-RELATED HEALTH
CHANGES CONDITION
Neuromuscular RELATED
Slowing of muscle Impaired postural alignment
timing/sequencing
Decreased ROM/flexibility Osteoporosis with vertebral
fracture
and kyphosis
Decreased muscle endurance Diabetes with distal motor
neuropathy
Decreased lower extremity Lower limb joint diseases
muscle (such as
strength, torque, and power arthritis)
Delayed distal muscle Spinal stenosis
latency
Increased cocontraction
Impaired postural alignment
(such as kyphosis)
INTRINSIC FALL RISK
FACTORS
AGE-RELATED HEALTH
CHANGES CONDITION
RELATED
Cardiovascular Conditions association
with
syncope or
lightheadedness
(arrhythmia, orthostatic
hypotension, etc.)
Psychosocial
Fear of falling Depression
Cognitive impairment
Other Incontinence
Alcohol abuse
Assessing depth perceptionA, The right hand is closer and is slowly moved away from the patient until the fingers align an
equal distance from the patient’s face. B, The patient reports that the fingers are of equal distance from their face.
The sensory organization test (SOT) of computerized
dynamic posturography. The physical therapist is guarding the
patient but not touching them during the testing
Six Testing Conditions of Sensory
Organization Testing Using
Posturography
Condition 1 Person stands on the force plate with eyes open,
feet together. There is no movement of the force
plate or the visual surround
Condition 2 Person stands on the force plate with eyes closed,
feet together. There is no movement of the force
plate or the visual surround
Condition 3 Person stands on the force plate with eyes open
and the platform surface is sway referenced to
visual surround (the floor moves commensurate
with the person’s sway).
Condition 4 Person stands on the force plate with eyes open
while the force plate is sway referenced, and fixed
visual surround
Condition 5 Person stands on the force plate with eyes closed
while the force plate is sway referenced
Condition 6 Person stands on the force plate with his or her
eyes open while both the force plate and the
visual surround are sway referenced
Functional Balance Measures
1.The Romberg test
2. The Tandem (sharpened) Romberg test
3. Single-leg stance (SLS)
4. Functional reach
5. The MultidirectionalReach Test(MDRT)
6. Five times sit to stand test(FTSST)
Response Strategies to Postural
Perturbations
Five basic strategies, depicted have been identified
as responses to unexpected postural perturbations.
The strategy elicited depends upon the amount of force
created and the size of the BOS during the perturbation:
1.Ankle strategy
2.Hip strategy
3.Stepping strategy
4.Reaching movement
5.Suspensory strategy
1.Ankle strategy
An ankle strategy is the activation of muscles around
the ankle joint after a small disturbance of BOS when
standing on a “normal” support surface.
The latency is approximately 73 to 110 ms with a distal-
to proximal muscle sequence.
Horak and Nashner have suggested that one may be able to
“train” people to execute an ankle or hip strategy based on
training paradigms
1.Ankle strategy
A significant amount of ankle strength and mobility is
a requisite for successful execution of an ankle strategy.
One might use an ankle strategy in order to maintain
balance with a slight perturbation of the trunk or center
of mass such as reaching for objects in front of you off
of a shelf without taking a step.
2.Hip strategy
A hip strategy is the activation of muscles around
the hip joint as a result of a sudden and forceful
disturbance of BOS while standing in a narrow support
surface. The latency is the same as in the ankle
strategy; however, the muscle sequence follows a
proximal-to-distal pattern. It has been suggested
that older adults often utilize the hip strategy rather
than an ankle strategy.
A combination of both ankle and hip strategies was
reported while standing in an intermediate support
surface.
In both ankle and hip strategies, muscle activity is
generated to keep the COG within the BOS. However, if
the disturbances are more forceful to put us at the edge
of a fall, other movements must occur that change the
BOS to prevent falling
3.Stepping strategy
The stepping strategy has been defined as taking a
forward
or backward step rapidly to regain equilibrium
when the COG is displaced beyond the limits of the
BOS. This can be observed clinically by resisting the
patient enough at the hips to cause a significant loss of
balance requiring one or more steps to maintain postural
control. It is very important to recognize when
and if a patient can utilize a balance control strategy to
optimize their postural control.
4.The reaching strategy
The reaching strategy includes moving the arm to
grasp or touch an object for support. Arm movements
play a significant role in maintaining stability
by altering the COG or protecting against injury.
Stepping and reaching strategies are the only
compensatory
reactions to large perturbations; thus, they have a
significant role in preventing falls. In unexpected
disturbances of balance, older adults tend to take
multiple
steps to recover, with the later steps usually directed
toward recovering lateral stability.
5.Suspensory strategy
The suspensory strategy includes bending knees during
standing or ambulation for the purpose of maintaining
a stable position during a perturbation. Bending of the
knees usually lowers the COG to be closer to the BOS,
thereby enhancing postural stability.
The sequencing and timing of muscle contraction
appears to undergo changes with advanced age including
delay in distal muscle latency and increases in the
incidence of co-contraction in antagonist muscle groups.
Older adults with a history of falls demonstrate
greater delay in muscle latency when compared to
age-matched nonfallers.
In a recent study, older adults
showed slower reaction times to change the direction of
the whole body in response to an auditory stimulus
compared
to young individuals, and moved in more rigid
patterns indicating altered postural coordination.These
changes make it harder for an older adult to
respond quickly enough to “catch” themselves when
challenged with a large unexpected perturbation.
Assistant Devices
Hip pads
Mobility aids
Cane
Walkers
Wheelchairs
Bathroom aids
- Raised toilet seats
- Grab bars
Falls Prevention
Is Everyone’s
Concern
Objectives
Understand factors that affect balance in the
context of the individual, task, and
environment
Identify tests for clinical assessment of balance
Identify fall risk factors and prevention
strategies within the individual and
environment
Balance
medicalxpress.com
Posture
www.emergingwomen.com
Center of Gravity
mobilitymgmt.com
www.travelingyogaman.com
www.slideshare.net
Motor Components of Balance
Reflexes
Vestibuloocular Reflex (VOR)
Vestibulospinal Reflex (VSR)
Postural Responses
Automatic- Ankle, Hip, Suspensory, Stepping
Anticipatory
Volitional Postural Movements
Peripheral Motor Execution
Musculoskeletal
Range of Motion
Flexibility
Strength
Endurance
Neural
Cognitive
deafseniorsusa.blogspot.com
Dynamic Systems Overview
lookfordiagnosis.com
Other Factors Affecting Balance
Medical Conditions Affecting Balance
Heart Disease, Heart Failure
Stroke
Parkinson’s Disease
Hypotension
COPD
Diabetes, Peripheral Neuropathy
Peripheral Vascular Disease, Foot Deformities
Arthritis
Impaired Cognition
Impaired Vision
learnnottofall.com
Medications Affecting Balance
Ace Inhibitors, beta blockers, Angiotensin II
ReceptorAntagonists, Calcium Channel Blockers,
Antiarrthymics, Diuretics, Vasodilators
Antipsychotics (neuroleptics), Anxiolytics, benzodiazepines,
Antidepressants
Opioid Analgesics, Anticonvulsants, Skeletal Muscle Relaxants
Antihistamines
Antiparkinsonian Agents
Drugguide.com
coretrainingforsport.com
Changes in gait with aging
Average gait speed declines 12% to 16% per decade past 70
yrs.
Stride frequency increases
Stride length decreases at a given walking speed
Double support time increases
General Gait Assessment: What to look
for in the elderly person at risk for falling
Gait Characteristics of Fallers
Decreased trunk rotation
Increased knee flexion
Several small steps and reduced speed prior to stepping over
low obstacle (12”)
Shorter step and stride length
Slowed gait speeds
Decreased single leg support time and increased double limb
support time.
Exercise Recommendations for Older
Adults with Chronic Disease or Frailty 58
Balance
1-7 x/week, dynamic exercises focused on mobility, static
exercise focused on single leg stand, 4-10 different exercises
Progressive, targeting important postural muscle groups,
progress by decreasing base of support
Muscle Performance
2-3 x/week, 8 to 10 exercises
Aerobic Capacity
Chronic Dx - 3-5 x/week, 20-60 minutes, 50-70% Hr
max
Frailty - > 3 x/week, at least 20 minutes, 11-13 Borg Scale
Flexibility
3-7 x/week, 3-5 reps each major muscle group, 10-30 s. hold
Balance Testing
Test Objectives
Test Selection
2c2090f5fef0e14f0dcd4be0391175bb.jpg
GTY_elderly_old_man_walking_sk_140127_16x9_608.jpg
Balance Tests
Static Balance
Romberg, Sharpened Romberg, 4-Stage Balance
Dynamic Balance
Functional Reach, 30s Sit-Stand
Sensory Manipulation
Clinical Test of Sensory Interaction and Balance
(CTSIB)
Modified CTSIB/ Modified Romberg
Functional Measures
Tinetti POMA, Berg
Timed Up and Go (TUG), Dynamic Gait Index (DGI)
Static Balance
Sharpened Romberg 4-Stage Balance
www.acefitness.org rehabmed.blogspot.com
Dynamic Balance
Functional Reach
fnagi-06-00286-g001.jpg
Dynamic Chair Sit to Stand
Assess Lower Extremity Strength, Functional Mobility,
Balance
30 s to administer
Community Elderly
Score below normative scores average indicates falls risk
87-yrsold-chair-exersie.jpg
Sensory Manipulation
Clinical Test of Sensory Interaction and Balance
(CTSIB)
Modified CTSIB Modified Romberg
www.oandp.org
Tinetti Performance Oriented Mobility
Assessment POMA
Assesses Balance, Gait, and Fall Risk
Tested in elderly and neurologic populations
Involves position changes, gait maneuvers
Free, no training required
10-15 min to administer
16 items- 9 balance 7 gait
Item Scale 0-2 Max score 28
Fall Risk Score <19=High 19-24=Med 25-28=Low
Berg Balance Scale
Assesses Balance and Fall Risk
Tested in elderly and neurologic populations
14 items - static and dynamic balance activities
Scale 0-4 Max score 56
Fall risk 0-20=High 21-40=Med 41-56=Low
<45/56 used as fall predictor
Minimal Detectable Change 6.5
15-20 min to administer
Free, no training required
Timed Up and Go (TUG)
Assesses falls risk
Tested in elderly and neurologic populations
Free, no training required
<5 min to administer
>13.5 s is predictive of falls
>30 s corresponds with functional dependence
in persons with pathology
Dynamic Gait Index
Assesses Ambulatory Balance in the context of external
demands
Tested in elderly and neurologic populations
Free, no training required
<10 min to administer
Scale 0-3 Max Score 24
Fall Risk Score <19/24 >22/24= safe ambulators
Minimal Detectable Change 2.9
FALLS ARE NOT INEVITABLE
Falls Prevention
Exercise
Medical Management
Rehab
Adaptive Strategies and Devices
Supervision/Assistance
Home Safety
Home Safety
wjla.com
www.nationwideeducation.co.uk
www.nationwideeducation.co.uk
www.sensoryworld.org
www.nationwideeducation.co.uk
www.brookdale.com
Ken Taylor at 90
http://cycleseven.org
Summary
Extremely important to try to prevent falls in your older
patients and prevent future falls from your current fallers
Look at their meds, cognition, orthostasis, vision, gait,
balance
Encourage exercise to improve muscle strength and
balance
Consider assistive devices
Use OT for home safety assessments
Screen for fear of falling and counsel to improve mobility
Banana George
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