Falls remain an urgent public health concern, increasing in magnitude with the rapidly emerging and growing aging baby-boomer demographic. Older adults sustaining a prior fall are 3 times more likely to experience another fall within in a 12 month period compared to those without a prior fall. Falls occur commonly among older people who have no apparent balance deficits as well as those with visible or easily detected impairments representing the number one cause of non-fatal injurious trauma and the leading cause of emergency department visits, hospital admissions, and injurious death. The aftermath of an injurious fall stresses the healthcare system, frequently initiaiating a downward functional mobility spiral. Fall prevention / risk reduction is a primary focus of health care agendas incorporating development and implementation of comprehensive assessment tools and evidence-based multi-factorial interventions. The need for early identification of heightened fall risk in community-living older adult is imperative to achieve a decrease in fall rate, injury and death attributable to falls. 1,2,3
Despite the lack of consensus, falls are usually defined in the literature as any unintentional loss of balance during routine activities resulting in contact with the ground or a lateral lower level. Acute medical events and extreme environmental causes typically are excluded.
A fall reporting scale, the 4-Point Hopkins Falls grading Scale (HFGS) was developed and validated: Grade 1– near fall slip or trip no ground contact; Grade 2- fall to ground or lower level no medical attention; Grade 3- fall medical attention no hospitalization; Grade 4– fall and hospitalization.4
Fall Risk Factors
Intrinsic non-modifiable: age, gender, race, and chronic disease.
Intrinsic modifiable: acute illness, incontinence, fall history, gait/mobility impairments, visual / sensory deficits.
Extrinsic modifiable: medications-polypharmacy /side effects, home hazards, footwear, behavior.6
Age- related changes include: impairments in somato-sensory and mechanical receptor responsiveness and vestibular mediated visual and sensory integration deficits causing dizziness and unsteadiness; slower nerve conduction velocity; decreased response amplitude; increased reaction time, muscle response latency, postural sway velocity and anterior-posterior sway. These factors may negatively impact safety, body position awareness and responses to perturbation,7,8 increased stride width, reduced gait speed, stride-to-stride variability, gait path deviation.9 Age-related changes in physical fitness include loss of 20-40 % maximal strength by age 65 in sedentary adults; decreased ankle dorsi-flexion power, hip strength and knee extensor strength are associated with falls in older adults.10 Other modifiable age related changes possibly associated with higher fall risk include: reduced lung volume and capacity; reduced cardiac output; increased systolic blood pressure and peripheral resistance; prolonged recovery time with relative greater work rate during physical activity; increased reliance on anaerobic metabolism; reduced flexibility due to decreased elastin and increased collagen muscle tissue. Available data in general indicates an inverse relationship between physical fitness and falls.6
Revised American Geriatrics Society (AGS) guidelines specify for individuals 65 years of age and older an expanded annual fall risk screening and assessment to include fall history, balance and gait assessment, with a comprehensive multifactorial fall risk assessment performed by a skilled trained clinician in presence of positive balance/gait findings. AGS guidelines recommend individuals reporting a single fall, demonstrating negative gait / balance findings do not require a multifactorial assessment. 11 Considering it takes only one fall to producedeleterious effects, it may not be appropriate to recommend “no intervention” as an option when addressing the public health importance of preventing falls in older adults. People with modifiable risk factors without a prior fall, will benefit from treatment.12
Comprehensive Fall Risk Assessment
Components: Relevant history, physical exam, cognitive and functional assessment, fall history, medication review, gait, balance, mobility assessment, visual acuity, neurologic impairments, muscle strength, heart rate and rhythm, postural hypotension, feet and footwear, environmental hazards.2
AGS evidence-based level A and level B Recommended Interventions
Home modifications; reduction of psychoactive medications; balance, strength, flexibility, endurance and gait training exercise; management of postural hypotension; reduction in poly-pharmacy. 11
Performance Components of Balance and Fall Risk
The primary objective of a falls prevention intervention program is to identify persons at risk of falling. Clinical tests and measures must: discriminate between groups, predict a result or expected outcome, and evaluate change over time. In selecting a screening tool various aspects must be taken into consideration including: sensitivity, specificity, reliability, clinical feasibility (cost, time, space), validating populations, meaningfulness of findings and limitations of the instrument
Effective and efficient static and dynamic postural control is context specific involving reactive and proactive balance / postural responses.
Proposed balance elements include: biomechanical constraints, stability limits, transition / anticipatory postural adjustment, reactive postural response, sensory orientation, gait stability.12 Measures of balance for the community-living older adult should be more challenging, more discriminating and include items of greater task and environmental complexity to better replicate postural demands in real-world environments. 14
Fall Risk Screening and assessment: Evidence-based tools
Semmes-Weinstein mono-filament testing (tactile sensitivity); tuning fork (vibration), Snellen eye test (visual acuity, static/dynamic); Melbourne edge test (contrast sensitivity PAP component); Dix-Hallpike / horizontal canal (BPPV) VNG, RealEyes x DVR, Micromedical Technologies Inc; Modified Clinical Test of Sensory Interaction on Balance (MCTSIB), Airex Balance Pads; Sensory organization test (SOT) Equi Test, NeuroCom International, Inc; Frailties and Injuries: Cooperative Studies of Intervention Techniques – 4, (FICSIT-4); Dynamic balance assessment (DBA);
Computerized Dynamic Posturography (Smart Equitest Neurocom International, Inc., Balance Quest Micromedical Technologies, Inc.; computerized gait assessment, GaitRite, CR Systems, Inc.; Limits of Stability force platform technology, MatScan with Sway Analysis, TekScan, Boston; Acceleromerty Movement Analysis, Mobility Lab, APD Oregon; TUGT; BBS; DGIm; Functional gait assessment (FGA); Tinetti POMA; 4 square step test (4SST); 5 times stand sit test (5XSST); Fullerton Advanced balance Scale (FAB); Functional Gait Assessment (FGA); BRIEF-BESTest; Short physical performance battery (SPPB), Voluntary Step Execution Test, Community Balance and Mobility Scale (CB&M), Walking and Remembering Test (WART); Sit and Reach Test, (Leighton Flexometer, Inc. Spokane); RIPPS Balance Method (Repeated Incremental Predictable Perturbations,( GNR Rehabilitation, Ocala Fl.).
The following tools assess components of fear or activity restriction.
Fall Risk assessment & Screening Tool (FRAST); Modified Falls Efficacy Scale, (mFES), Modified Gait Efficacy Scale (mGES), Activities-specific Balance Confidence short version (ABC-6), Fear of Falling Avoidance Behavior Questionnaire (FFABQ), Survey of Activities and Fear of Falling in the Elderly (SAFE), Physical Functioning Scale of the Short-Form (SF) 36.
Prior to exercise, all fall risk factors should be assessed and triaged appropriately.
Exercise interventions should be structured and progressive, tailored to the specific needs of the individual and achieve optima dose. Recommendations differ for frail institutionalized and non-frail community-living groups. 2
Evidence suggests for community-living older adults, recommended exercise dose is to be 50 hours over a period of 3 to 6 months.2
Moderate to high challenge balance training has been reported to be the only mode of exercise that had significant protective effect on the rates of falls (estimated 25 % reduction). Other evidence-based modes of exercise include: strengthening, stretching, dynamic gait training, dual-task training, walking, integration, perturbation and compensatory stepping.2
Adaptation to repeated perturbations and stepping responses for the purposes of fall risk identification and development of balance intervention strategies in healthy and impaired older adults has received recent interest .15-23 Postural reaction time is a strong determinant of falls risk.21 Strong associations between tether- release stepping recovery responses and biomechanical parameters such as step length, step timing and joint torques point to the importance of neuromuscular capacities that relate to lower extremity flexibility, reaction time and strength. The maintenance or enhancement of these core attributes should be considered when developing exercise-based fall intervention programs for older adults.
Original work by DePasquale and Toscano, The Spring Scale Test: A Valid and Reliable Tool for Explaining Fall History. Jl Geriatr Phys Ther. 2009, provides the evidence-based foundations of the RIPPS Balance Method. RIPPS (repeated incremental predictable perturbations) is a highly discriminant, reactive / proactive perturbation clinical tool validated on community-living older adults. The RIPPS percent of total body weight (% TBW) clinical performance measure quantifies stepping frequencies and responses at threshold % TBW, 10% TBW and limit % TBW milestones for the purposes of fall risk assessment and induced-stepping intervention. The RIPPS 10 % TBW performance value was most discriminant to fall status compared to 4 other measures examined. RIPPS intervention goals include, increased threshold and directional limit stepping % TBW force, and / or reduced number of steps required to maintain effective balance at RIPPS measurement milestones, with the net effect of development of quicker postural responses with enhanced adaptation to repeated perturbation. 22
Exercise Mode Specific Tools
Flexometer, Acuflex I, adjustable slant boards, (Stretchwell), Prostretch, looped stretch straps, OPTP, Kyphosis / forward head reduction management , lumbar roll /cushion OPTP
Eccentron, BTE, NuStep T4r, ResQup (Safe Patient Solutions), Elastic tubing and band, ( Hygenic, TherapyZone, CanDo), body weight closed chain patterns.
Biodex Balance System SD, HUMAC Balance System (CSMi), Korebalance Premiere, (Med-Fit Systems Inc), Nintendo Wii Fit, (Nintendo of America, Inc), Bungee Trainer (NeuroGym Technologies), RIPPS Balance Method, (GNR), Balance-Based Torso Weighting, BBTW, (Motion Therapeutics), Wobble and rocker boards, (Bosu) Stability Trainers (Hygenic), Balance Pads (Airex), Fitter Slide mats and Fitter Soft Boards, (Fitter International), Stepping Wolf, (Stretchwell). ValSlide plastic discs and booties, Stacking platforms, Body bars (Hygenic).
RIPPS Balance Method, GNR
BalanceWear by Motion Therapeutics is an evidence-based, proprioceptive, neuromuscular strategic weighting body torso device, developed by a physical therapist.22
GaitRite, CR Systems, Inc.; Bungee Trainer, NeuroGym Technologies,; ZeroG Gait and Balance Training System, Aertech LLC.
Strengthening: Swifter pad/sponge mop, padded PVC T-bar for resistive ankle dorsi-flexion..
Foam pipe insulation alone or with cane / broomstick insert, varying diameters for ankle rocking or inclined standing tasks; telephone books for platform step tasks and inclined stand tasks; step stool for alternate stepping tasks; plastic lids for low friction standing foot slide tasks; Swifter or Broomstick, (bristle side down) for uncertain support surface during modified single limb or narrow / semi tandem standing tasks. View Master, hand held, for visual conflict sensory integration tasks.
Thoughtful selection of measures, appropriate for the target population, clinically feasible, and psychometrically sound, for assessing physical function of community –living older adults and frail older adults is an essential step along a path toward evidence-based practice in geriatric physical therapy.
References For This Article:
- Centers for Disease Control Web site. Available at: http://www.cdc.gov/ncipc/factsheets/adultfalls.htm. Accessed July 30, 2008.
- Cumming RG, Nevitt MC, Cummings SR. Epidemiology of hip fractures. Epidemiol Rev. 1997; 19: 244-257.
- Arnold CM, Faulkner RA. The history of fall and the association of the timed up and go test to fall and near-falls in older people with osteoarthritis. BMC Geriatr. 2007; 7:17 (9 pages).
- Binder EF, Brown M, Sinacore DR, Stega-May K, et al. Effects of extended outpatient rehabilitation after hip fracture: a randomized controlled trial. JAMA. 2004; 18: 837-846.
- Boulgarides LK, McGinty SM, Willett JA, Barnes CW. Use of clinical and impairment-based tests to predict falls by community-dwelling older adults. Phys Ther. 2003; 83: 328-339
- Thrane G, Joakimsen RM, Thornquist E. The association between the timed up and go test and history of falls: The Tromso study. BMC Geriatr. 2007; 7: 1 (7 pages).
- Nordin E, Lidelof N, Rosendahl E, Jensen J, Lundin-Olsson, L. Prognostic validity of the timed up-and go test, a modified get-up-and-go test, staff’s global judgment and fall history in evaluating fall risk in residential care facilities. Age Aging. 2008; 37: 442-448.
- Lin MR, Hwang HF, Hu MH, Wu HD, Wang YW, Huang FC. Psychometric comparisons of the timed “up and go”, one-leg stand, functional reach and Tinetti balance measures in community-dwelling older people. J Am Geriatr Soc. 2004; 52: 1343-1348.
- Pai YC, Wang E, Espy D, Bhatt T. Adaptability to perturbation as a predictor of future falls: A preliminary prospective study. J Geriatr Phys Ther. 2010; 33(2) 50-61.
- Harris JE, Eng JJ, Marigold DS, Tokuno CD, Louis CL. Relationship of balance and mobility to fall incidence in people with chronic stroke. Phys Ther. 2005; 85: 150-158.
- Schultz BW, Ashton-Miller JA, Alexander NB. Compensatory stepping in response to waist pulls in balance-impaired and unimpaired women. Gait Posture. 2005; 22: 198-209.
- Tseng S, et al. Impaired reactive stepping adjustments in older adults. J Gerontol A Bio Sci Med Sci . 2009; 64a: (7) 807-815.
- Mansfield A, et al. Effect of a perturbation-based balance training program on compensatory stepping and grasping reactions in older adults: A randomized controlled trial. Phys Ther. 2010; 90: (4) 476-91.
- Pai YC, Bhatt T. Rpeated slip training: An emerging paradigm for prevention of slip-related falls among older adults. Phys Ther. 2007; 87: (11) 1-13.
- Mansfield A, Peters AL, Liu BA, Maki BE. A perturbation-based balance training program for older adults: study protocol for a randomized controlled trial. BMC Geriatr. 2007; 7: 12 (17 pages).
- 16. Badke MB, Duncan PW, DiFabio RP. Influence of prior knowledge on automatic and voluntary postural adjustments in healthy and hemiplegic subjects. Phys Ther. 1987; 67: 1495-1500.
- Diener HC, Horak F, Stelmach G, et al. Direction and amplitude precuing has no effect on automatic postural responses. Exp Brain Res. 1991; 89: 219-223.
- DePasquale L, Toscano, L. The spring scale test: A reliable and valid tool for explaining fall history. J Geratr Phys Ther. 2009; 32 (4): 159-167
- Pai YC, Wening JD, Runtz EF, Iqbal K, Pavol MJ. Role of feedforward control of movement stability in reducing slip-related balance loss and falls among older adults. J Neurophysiol.2003; 90: 755-762.
Louis DePasquale PT, MA
Latest posts by Louis DePasquale PT, MA (see all)
- Association Of Protective Stepping With Fall History - November 17, 2016
- Fall Prevention: Current Perspectives, Tools with Evidence - April 1, 2014
- Performance Measures: Does Performance Really Measure Up? - April 1, 2014
- Predictable Perturbations: An Innovative Clinical Perspective - September 30, 2008