Balance & Fall Interventions for Fall Preventions

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Physical therapists often play a reactive role in fall prevention. That is, we do not create a tailored and personalized fall prevention program for an older adult until they have already experienced a fall and subsequently seek our services. Physical therapists are in an important position within the healthcare environment to help create a shift from reaction to prevention regarding falls. For example, assume that you are working with an older adult in an outpatient clinical setting who is experiencing neck pain after being rear-ended in a car accident.  A falls assessment should be a part of your examination of this patient/client even though the primary complaint may be neck pain.  Fall risk factors can be identified and fall prevention interventions can be either incorporated into the current plan of care, a separate fall prevention plan can be created or an appropriate referral to a fall prevention community-based exercise program can be made.

It is important to recognize in the scenario above, that prescribing a HEP to target fall prevention is not enough to affect fall risk in an older adult who possesses risk factors for falls. In other words, the dosage of high-intensity balance and strengthening exercises required to affect fall risk exceeds that which would likely occur within a HEP that supplements a plan of care for an alternative health condition such as neck pain after a motor vehicle accident. In a systematic review of the literature in 2008, Sherrington et al reported that at least 50 hours of exercise is required to affect an older adult’s fall rate. (provide link to article) This dosage is now widely accepted as the appropriate duration of exercise required to reduce the risk and rate of falls in those 65 and older. The frequency with which this 50 hour minimum is achieved is also important. Sherrington et al indicate that interventions delivered in less than 12 weeks did not consistently reduce the risk or rate of falling. They conclude that individuals who start an exercise program but do not achieve the minimum dose of 50 hours over at least a 12 week time frame may actually be at a higher risk of falling than before starting the exercise program.  Thus, for a HEP to meet these requirements it would have to be performed for at least 35.5 minutes per day for at least 12 weeks.  This is valuable information to consider when you are educating your patient/client about fall risk reduction and initiating exercise to decreased fall rate and risk.;

The National Center for Injury Prevention and Control of the Centers for Disease Control and Prevention developed a resource titled, Starting Your Own Community Based Fall Prevention Program for Older Adults, in 2008 which may be a helpful guide in determining what type of program may fit into your community.

Senior Centers and YMCAs may already have established community fall prevention programs for older adults. 

The Department of Elder Affairs in the State of Florida provides information about the evidence-based programs currently available in Florida. (provide link)

This may be a good place to create a Learn More about Fall Prevention Intervention link that links to the info below.

An older adult’s susceptibility to a fall is multifactorial.  The actual cause of a fall is also multifactorial.  Therefore, interventions to prevent falls in older adults must also be multifactorial. Because of this, it may be helpful to think of fall prevention within a framework of age-related changes:

  • Auditory System
  • Autonomic Nervous System
  • Cardiovascular System
  • Central Nervous System
  • Musculoskeletal System
  • Neuromuscular System
  • Peripheral Nervous System
  • Pulmonary System
  • Somatosensory System
  • Visual System
  • Vestibular System

Changes in postural control result from changes within all of the systems listed above and include:

  • Increased postural sway in quiet stance
  • Altered muscle activation in response to a perturbation
  • Altered ability to modulate movement
  • Altered movement timing and coordination
  • Slowed reaction time in response to a stimulus
  • Slowed cognitive functions such as executive functions and sequencing tasks

Implementing the appropriate fall prevention interventions for your patient/client requires a calculated screening and assessment process so that the appropriate systems can be targeted. For example, improving an older adult’s lower extremity strength may not be a comprehensive enough intervention strategy if the older adult is falling due visual changes such as poor contrast sensitivity or a combination of central and peripheral nervous system changes such as slowed reaction time when center of mass is challenged.  As physical therapists we may hone in on improving the musculoskeletal and neuromuscular systems however it is important to recognize other factors as well such as multiple comorbid conditions that require multiple medications, nutritional and dietary factors, and environmental factors to name a few.

General strategies for implementing fall prevention interventions with older adults include the following:

  • Create an organized structure with a clear goal or goals for that particular activity whether this is within an individualized session or within a group class. For example, explain the salience behind repeated sit-to-stand practice from varying heights such as improving the ability to get off the commode, out of a car or off a chair in a restaurant. Providing your rationale for why you are asking an older adult to complete a certain task, especially one that is difficult, will not only help to develop a rapport with your patient/client but will also help to engage them as a member of their healthcare team.
  • Allow for self-paced tasks. As indicated above, reaction time and cognitive functions are slowed. They are NOT absent in a healthy aging older adult. In addition, the auditory system has also likely changed. Thus, allow time for your patient/client to hear, process, and develop a response to something you have asked of them or demonstrated for them.
  • Communicate with your patient/client at a close distance so that you can ensure that the message you intend to communicate has been received. This will afford you the ability to observe your patient/client’s reaction and the ability for your patient/client to respond to you.
  • Reduce interfering noise. Since accelerated speech and loud sounds contribute to sound distortion it is best to facilitate an environment where sound can be localized for optimal communication and learning.
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