Balance: Decreasing Fall Risk. Presented By: Jennifer Bell, MSPT, DPT Contributors: Katie Aakre, DPT; Patty Carroll, OTR/L

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1 Balance: Decreasing Fall Risk Presented By: Jennifer Bell, MSPT, DPT Contributors: Katie Aakre, DPT; Patty Carroll, OTR/L

2 Presentation Objectives Identify factors that increase risk of falling Understand the role of the musculoskeletal, neurological, and vestibular systems in balance Understand how to screen for falls risk Understand how to improve balance

3 Facts & Statistics Falls are a major public health concern Falls are a leading cause of injury related death and non-fatal injury in the U.S. According to the CDC, each year three million older people are treated for fall injuries in emergency departments One out of five falls causes a serious injury including broken bone or head injury Less than half of people who fall tell their doctor

4 Falls are costly! 40% of all nursing home admissions are in some way related to fall The average cost per fall is >$30,000! (Tinetti, 1988) Direct medical costs for fall injuries totals >$28 billion annually Medicaid and Medicare are responsible for the majority of these costs

5 Falls and hip fractures Each year, over 300,000 older people (>65 years old) are hospitalized for hip fractures 25-50% of those who sustain a hip fracture from a fall die within one year More than 95% of hip fractures are caused by falling, usually by falling sideways Women experience three-quarters of all hip fractures Women fall more often than men Osteoporosis

6 How do you define a fall? According to CMS, a fall is an episode where a person lost his/her balance, and would have fallen, were it not for staff intervention Injury is not a factor in the determination of a fall Many patients do not report falls because they don t sustain injury According to the WHO, a fall is defined as an event which results in a person coming to rest inadvertently on the ground or floor or other lower level According to the American Nurses Association, a patient fall is an unplanned descent to the floor

7 What increases fall risk for our patients? Musculoskeletal impairments Age Cognition Pain Neurological problems History of stroke, TBI, Parkinson s Disease, MS Environmental factors Outdoor hazards Hazards in the home Medication considerations Orthostatic hypotension Vision problems Vestibular Dysfunction

8 Musculoskeletal impairments ROM Strength Gait Impaired somatosensory system

9 Musculoskeletal impairments: ROM Patients need adequate ROM in ankle, hip and trunk for postural adjustments to prevent a fall Ex: need at least 5-10 degrees of ankle dorsiflexion for ankle strategy Decreased ROM of the spine and increased kyphosis can lead to a stooped posture Loss of spinal flexibility can also contribute to a shift in center of mass Arthritis

10 Musculoskeletal impairments: strength Patient s need sufficient strength to produce a force strong enough to correct a perturbation Muscle strength is directly proportional to gait velocity (Bendall et al. 1989) Muscles active during stance: Gastroc/soleus, and tibialis anterior Gluteus medius, and TFL Iliopsoas Erector spine and abdominals

11 Musculoskeletal impairments: changes in gait Gait speed declines with aging Decreased power Impaired balance Gait pattern changes Shortened stride and step length More time in stance phase Hips slightly flexed Toe out foot position Widened BOS Poor plantar flexion power in terminal stance (Judge et al. 1996)

12 Musculoskeletal impairments: somatosensory system Arises from muscle, joint, skin, fascia Gives us conscious perception of pressure, pain, touch, movement, position Constantly active, providing input to the soles of the feet This contributes to postural reactions Ex: center of mass is displaced forward and plantar flexors activate

restraints Muscles prepare before actual movement occurs Muscle groups work in synergy

13 Postural reactions and anticipatory control Anticipatory control: patient s ability to prepare for displacement Influenced by experience, practice, knowledge of physical restraints Muscles prepare before actual movement occurs Muscle groups work in synergy as a unit to recover stability after center of mass is displaced to produce a postural reaction

14 Postural reactions Postural reactions Ankle strategy Initial strategy Forward fall: gastrocnemius, hamstrings, paraspinals Backwards fall: anterior tibialis, quadriceps, abdominals Hip strategy Larger perturbations Forward fall: abdominals, quadriceps Backwards fall: paraspinals, hamstrings Stepping strategy Final strategy Very strong perturbation Center of mass is outside base of support

somatosensory system 20% vestibular system 10% visual system On an

15 Sensory strategies On different surfaces, our body relies on different systems to allow us to balance On a firm surface 70% somatosensory system 20% vestibular system 10% visual system On an unstable surface 60% vestibular system 30% visual system 10% somatosensory system

16 Dementia and memory loss Independent risk factor for falling Impaired judgement, gait, visual-spatial perception, and ability to avoid and recognize hazards In one study, the fall rate for residents in a nursing home with dementia was 4.05 falls per year, compared with 2.33 falls per year for residents without dementia (Van Doorn et al. 2003)

17 Neurological Problems Parkinson s Disease Multiple Sclerosis Neuropathy Stroke TBI

18 Neurological impairments: Parkinson s Disease Image credit: The Dana Foundation, dana.org Postural instability Typically in later stages Causes a forward or backwards lean - stooped posture Anticipatory postural adjustments are impaired or absent Most commonly in posterior direction Bradykinesia Slowing of movement Increased reaction time Gait difficulties Freezing Festination

19 Neurological impairments: multiple sclerosis Weakness due to deconditioning or damage to nerves Fatigue Spasticity More common in legs, but can occur in any limb Vision problems such as blurred vision Numbness/tingling in extremities

Neurological impairments: peripheral neuropathy Damage to the peripheral nervous system Sensory nerves Numbness Tingling Motor nerves Weakness Muscle spasms Muscle atrophy Image credit: Living

20 Neurological impairments: peripheral neuropathy Damage to the peripheral nervous system Sensory nerves Numbness Tingling Motor nerves Weakness Muscle spasms Muscle atrophy Image credit: Living with Diabetes. Diabetes.org. Diabetes Kidney failure Small vessel disease Infection Cancer Genetic diseases Exposure to toxins Autoimmune conditions RA, Sjogren s, lupus, MS, CIDP, Guillain-Barre

21 Neurological impairments: stroke Falls is one of the most common complications of stroke Prevention of falls is one of the most important factors in recovery of independent ADL s Reduced muscle tone Paralysis Impaired dynamic balance Patients with hemiplegia > hemiparesis are at higher risk for falls (Tsur, 2010)

Neurological impairments: traumatic brain injury Acute brain injury Mild TBI and concussion Post concussion symptoms: headache, fatigue, anxiety, nausea, emotional lability, cognitive problems

22 Neurological impairments: traumatic brain injury Acute brain injury Mild TBI and concussion Post concussion symptoms: headache, fatigue, anxiety, nausea, emotional lability, cognitive problems Between 40-80% of individuals exposed to mild head injury experience some post concussion symptoms. Most recover within days to weeks, and about 10-15% have complaints after one year Chronic brain injury Repetitive head trauma Catastrophic brain injury acute severe brain injury Intracranial bleeding or cerebral contusions Balance, vestibular, and visual impairments (Blennow et al. 2012) Image credit: Sports concussion. UCLAhealth.org

23 Environmental Factors-Home Modification Keep pathways clear and be aware of where your are walking including uneven surfaces Get rid of all rugs Keep frequently used items close by Light your way Add supports to the bathroom Stay safe on the stairs (Fall Prevention Center of Excellence, 2012)

24 Preventing Medication Related Falls Common medications for the following health problems may increase fall risk: Heart and blood pressure Sleep, anxiety and depression Dementia symptoms Arthritis and pain Bladder control Digestive, stomach and nausea Blood Clots Colds, flu and allergies (Fall Prevention Center of Excellence, 2012) Medication Side Effects that Increase Fall Risk: Dizziness Orthostatic hypotension Slow response to loss of balance Loss of concentration Decreased alertness, drowsiness Blurred vision

25 Vision Loss and Fall Risk Individuals with vision problems are more than twice as likely to fall as people without vision problems. (Fall Prevention Center of Excellence, 2012) Effects of vision loss Difficulty with balance Difficulty seeing obstacles Difficulty seeing steps/curbs Reduced activity resulting in decreased strength

26 The Vestibular System and Balance To maintain balance, information from the vestibular, visual and somatosensory systems are integrated within the central nervous system. The vestibular system is a primary contributor to equilibrium as it references where our head is in space. Vision and somatosensory are references that tell our brain about the world outside. When there is a conflict between these references, the result is the brain s inaccurate perception or hallucination of motion (vertigo). This can result in a loss of balance or a fall The vestibular system can be damaged by disease, aging, poisoning by drugs, or injury. Many vestibular disorders occur from unexplained causes.

Vestibular anatomy The vestibular system consists of a peripheral and a central portion Peripheral - includes a labyrinth that is lined with hair cells(cilia) and is filled with fluid.

27 Vestibular anatomy The vestibular system consists of a peripheral and a central portion Peripheral - includes a labyrinth that is lined with hair cells(cilia) and is filled with fluid. Head motion causes the fluid to move. The moving fluid bends the cilia and this leads to neural firing of the vestibular nerve Central includes the brain and brainstem. The central vestibular system process all the balance and spatial information coming in Image credit: anatomy of vestibular system. anatomysciences.com

28 Vestibular Facts 80% of individuals aged >65 years have experienced dizziness and BPPV (benign positional paroxysmal vertigo). Vestibular disorders are difficult to diagnose. It is common to seek care from several providers over a period of many years before receiving an accurate diagnosis. There is no cure for most vestibular disorders. They can be treated with therapy, medication, surgery and life style changes.

29 Common symptoms of vestibular dysfunction Dizziness and Vertigo Nausea/vomiting Imbalance Spatial disorientation Vision disturbance Hearing changes Cognitive and/or psychological changes Other-tinnitus, fatigue, anxiety

30 Screening for balance and falls risk In physical therapy, we use a variety of different balance tests and measures depending on patient function Examples commonly used in outpatient: Timed Up and Go (TUG) 30 second sit to stand Gait speed 4 square step test Functional reach test Tinetti mctsib Berg Balance Assessment Dynamic gait index Functional gait index HiMat Mini-BESTest 6 Minute Walk Test

31 Tests covered today 1. Timed get up and go second chair stand test 3. Gait speed 10 M walk test

32 Timed Get Up and Go Test Purpose: quick screening tool to measure functional mobility in community dwelling adults (Podsiadlo, 1991) Task: Patient is instructed to rise from a chair, ambulate 3 meters (10 feet), turn 180 degrees, ambulate back to the chair and return to sitting Equipment Marked line at 10 feet Standard chair Watch Assistive device is optional 3 timed trials taken 1 practice 2 timed trials, average taken

33 Timed Get Up and Go Predictive validity: seconds = normal >13.5 seconds indicative of falls risk 20 seconds indicative of frail for functional independence >30 seconds indicative of dependence (Boulgarides, 2003) Other variations for dual task: TUG Motor Carry a cup of water TUG Cognitive Counting backwards by 3 s from 100

34 The 30-Second Chair Stand Test Purpose: to assess leg strength and endurance Task: Patient is instructed to sit in the middle of the chair with arms crossed to opposite shoulder, feet flat on the floor, back straight On Go, patient rises to full standing and back to sitting Repeated for 30 seconds Equipment Standard chair Watch

The 30-Second Chair Stand Test Patient can be allowed a warm-up trial for correct form If patient cannot stand without use of arms, stop the test Score of 0

35 The 30-Second Chair Stand Test Patient can be allowed a warm-up trial for correct form If patient cannot stand without use of arms, stop the test Score of 0 Allowed to repeat test using upper extremity support on standard chair Below average score indicates high falls risk Image credit: physical measures. Duke.edu.

36 Chair stand average scores Age Men Women <14 < <12 < <12 < <11 < <10 < <8 < <7 <4 (Center for Disease Control)

37 Gait Speed Can be assessed quickly and accurately Improvements in walking speed can be linked to clinical meaningful changes in quality of life Easy to use as a predictor and outcome measure for many diagnoses The 6 th vital sign Not a measure of endurance

38 Gait Speed: 10 meter walk test Purpose: to identify risk for falls Task: patient is asked to walk at your normal, comfortable speed over a 10 meter distance Middle 6 meters is timed Equipment: 20 m path, stop watch Can also test for maximum walking speed, walk as fast as you can With increased age, maximum gait speed declines more steeply than comfortable gait speed (Bohannon et al. 1997)

39 Gait Speed: 10 meter walk test Image credit: gait speed.dovepress.com

40 Gait speed norms for health populations Age Comfortable Mean (m/s) Fast Mean (m/s) female ± male ± female ± male ± female ± male ± female ± male ± female ± male ± female ± male ±.24 (Steffen et al. 2002)

41 What can we do?? Refer to Rehab for strengthening, Gait, ROM, Assistive device or vestibular rehabilitation Consider medication factors Suggest home modification Consider vision factors

42 Multifactorial interventions Tinetti et al. studied 301 men and women age >70 living in the community who had at least one risk factor for falling Intervention group: adjustments in medication, behavioral instructions, and exercise programs aimed at modifying risk factor Control group: usual health care plus social visits During 1 year follow up, 35% of intervention group fell as compared to 47% control group Significant reduction in risk for falling Total cost of the intervention was an average of $891 per subject The cost for preventing one fall that required medical attention was $12,392

43 Examples of rehab interventions Assistive device assessment and training Gait training Transfer training Recommendations for grab bars or railings Aerobic exercise Strengthening program Balance program

44 HealthEast Optimum Rehabilitation We re here to help! Come see us for physical or occupational therapy

45 Questions??? Please feel free to contact me with any questions Jennifer Bell, MSPT, DPT or

46 Thank You!

47 References 1. Bendall, M. J., et al. Factors Affecting Walking Speed of Elderly People. Age and Ageing, vol. 18, no. 5, 18 Sept. 1989, pp , doi: /ageing/ Blennow, Kaj, et al. The Neuropathology and Neurobiology of Traumatic Brain Injury. Neuron, vol. 76, no. 5, 6 Dec Bohannon, R. W. Comfortable and maximum walking speed of adults aged years: reference values and determinants." Age Ageing. 1997;26(1): Boulgarides, Lois K, et al. Use of Clinical and Impairment Based-Tests to Predict Falls by Community-Dwelling Older Adults. Physical Therapy, vol. 88, no. 4, HealthEast Falls Handouts, Fall Prevention Coalition Los Angeles, August Hip Fractures Among Older Adults. Centers for Disease Control and Prevention, CDC Injury Center, Sept. 2016, 7. Important Facts about Falls. Centers for Disease Control and Prevention, CDC Injury Center, Oct. 2017, 8. Judge, J O, et al. Effects of Age on Biomechanics and Physiology of Gait. Effects of Age on Biomechanics and Physiology of Gait, vol. 12, no. 4, 1 Nov Kihun, Cho, et al. Risk Factors Related to Falling in Stroke Patients: a Cross-Sectional Study. Journal of Physical Therapy Science, vol. 27, 2015, pp Koveleski Kraut, Sara. Evidence-Based Rehab Techniques for Parkinson's Disease, Multiple Sclerosis and Peripheral Neuropathy. North American Seminars, O'Sullivan, Susan B, and Thomas J Schmitz. Physical Rehabilitation. 5th ed., F.A Davis, Podsiadlo D, Richardson S. The timed Up and Go. A test of basic functional mobility for frail elderly persons. Journal of the American Geriatrics Society 1991; 39: STEADI Materials for Healthcare Providers. STEADI - Older Adult Fall Prevention, Centers for Disease Control and Prevention, 2017, Steffen, Teresa M, et al. Age- and Gender-Related Test Performance in Community-Dwelling Elderly People: Six Minute Walk Test, Berg Balance Scale, Timed up & Go Test, and Gait Speed. Physical Therapy, vol. 82, no. 2, Feb Tinetti, Mary E, et al. Risk Factors for Falls among Elderly Persons Living in the Community. The New Englad Journal of Medicine, vol. 319, Dec Tsur, A, and Z Segal. Falls in Stroke Patients: Risk Factors and Risk Management. Israel Medical Association, no. 4, Apr. 2010, pp Van Doorn, Carol, et al. Dementia as a Risk Factor for Falls and Fall Injuries among Nursing Home Residents. Journal of American Geriatrics Society, vol. 51, 2003, pp Top Ten Facts About Vestibular Disorders. Vestibular Disorder Association, August 2018,

48 HealthEast Care System is an approved provider of continuing nursing education by the Wisconsin Nurses Association, an accredited approver by the American Nurses Credentialing Center s Commission on Accreditation. No conflict of interest in planning, writing, reviewing, or editing of this program content was identified or discovered during the development of the class. No conflicts exist of personal, professional, or financial nature.

Gait Assessment & Implications in Geriatric Rehabilitation

Gait Assessment & Implications in Geriatric Rehabilitation Therapy Network Seminars, Inc. Nicole Dawson, PT, PhD, GCS Learning Objectives Following completion of this webinar, participants will be able