Falls Are On The Rise – Physical Therapy May Be The Best Medicine

Laura Thompson, PT DPT, GCS

Physical Therapist

If you could prescribe a medicine that would reduce your patients’ risk of falling by more than 25 percent, would you?

I hope so!

Good news: We as therapists can prescribe our patients specific exercises at moderate to high intensities to reduce their risk of falling by 25 percent or more. By now, we all know to look for risk factors for falls, including if our patients have experienced a fall in the past year, have a fear falling, are currently taking psychoactive medications, polypharmacy, use an assistive device, require assistance for activities of daily living, are dealing with incontinence, have impaired vision, or have environmental hazards such as throw rugs and dim lighting. These are all important topics to address during a patient’s plan of care and should not be overlooked.

For medication concerns, we strike up conversations with our patients’ physicians. Depending on severity and type of incontinence, we can educate on toileting schedules and exercises to strengthen pelvic floor. For impaired vision and environmental hazards, we can make suggestions on how to modify their home environment to reduce falls.

And the list goes on.

We can educate on many possible interventions to reduce fall risk and communicate with our interdisciplinary team about different interventions which is extremely important. But what makes us as clinicians stand out in the role of fall prevention?

When we dig deeper into not only what our patients’ deficits are but why they are experiencing those deficits, we stand out.

Are they shuffling their feet because they have poor strength?

Poor balance?

Fear of falling?

Coordination impairments?

Gastrocnemius and hamstring tightness?

It is our job to figure out why these gait or balance deficits are occurring and address them for our patients’ safety and functionality!

For instance, I had a patient who was functionally doing well in her community. She was able to rise out of chairs using her upper extremities and wide base of support and used a rollator appropriately to ambulate for over 1000 feet. However, when she was in her bedroom, she ditched the rollator and used no assistive device, and that’s where her trouble began. The patient had said most of her falls happened in her room but she didn’t know why because she walks all over her apartment complex just fine during the day (using her rollator). We talked about using rollator in her room to maintain safe ambulation; however, she declined because of the small spaces and the rollator being “in the way.” As we walked around her room without her rollator, she deviated from straight path multiple times, lost her balance when turning to talk to me, and could not smoothly turn 180 degrees to change directions.

So we worked specifically on ambulation without the assistive device, weaving around obstacles, cognitive and physical dual task (naming items in categories, head turns while walking), turning on command, and improving her balance reactions.

She is now able to safely navigate her bedroom without an assistive device and continues to safely use her rollator in the rest of her apartment complex.

WHAT DOES THE RESEARCH SAY ABOUT DOSAGE?

A patient requires sufficient challenges throughout treatment to create change. Physical therapists need to provide moderate-to-high level challenges for balance exercises three hours per week to make functional gains. We need to have our patients perform exercises specific to the underlying movement dysfunction. Our patients should be challenged to the point that they are only successful 75 percent of the time!

We need to examine the features of their postural alignment and balance reactions in order to provide task-specific approaches to prevent future falls. We need our patients to struggle and be challenged enough for their body to adapt and then overcome new adversities. Patient improvements come to light when the intensity is higher. Keep recalibrating what is challenging for our patients because it can change within a session!

ARE YOU CHALLENGING YOUR PATIENTS TO EXERCISE THEIR HIGHEST POTENTIAL?

In order to provide excellent clinical care, physical therapists must demand a lot of our skilled care but also of our patients’ capacity to grow stronger. It’s hard work to challenge our patients to their maximal potential, especially when working to improve their balance! Many older adults have experienced a fall and have a significant fear of falling. Now we are going to ask these older adults to take their hands off their assistive device, which they rely on for safe mobility?! That would sound a bit crazy to me too.

We have to develop a rapport with our patients and a level of trust in order to challenge them.

HOW PHYSICAL THERAPISTS CAN GO ABOVE AND BEYOND TO CHALLENGE OUR PATIENTS?

We need to challenge all balance components in our treatment sessions after we determine a patient’s baseline. Tests and measures that can be useful to assess a patient’s baseline include sitting balance test, functional gait assessment, and berg balance test. Once the baseline is established, we can start challenging our patients’ balance in the following ways:

• Reduce upper extremity support
• Reduce base of support (feet apart, feet together, semi-tandem, tandem and to one-leg stand)
• Stress postural muscles (weight shifting onto heels and then to toes)
• Reduce visual input (performing tasks with eyes closed)
• Challenge somatosensory system (standing on uneven or foam surface)
• Dual tasks (walking with head turns and walking while counting backward)
• Dynamic movements (turning 360 degrees, heel to toe walking, and walking backwards)
• Increase speed of a task
• Provide external perturbations
• Add obstacles to improve patient’s specific adaptations to imposed demands

We need to work on all of these things in parallel, not as isolated tasks.

HOW ARE YOU HAVING YOUR PATIENT LEVEL UP DURING SESSIONS?

What else can be done? How can we improve patients’ limits of stability and balance strategies?

We can start by having our patient reach forward and laterally as far as possible and analyze what their balance strategies are using to maintain their balance. Are they using ankle, hip, or stepping strategy? How can we adequately challenge our patient? How can we get them to utilize ankle strategy to maintain their balance?

I work with a patient right now who always says to me, “Isn’t anything ever good enough for you!?” I take that as the best compliment because as soon as she masters one balance task, I progress her right into something more challenging. For example, I advanced her from a narrow base of support (feet together) while performing horizontal head turns to perform the same task with semi tandem stance. A progression of her base of support totally changed the patient’s balance strategy from ankle strategy to utilizing hip and stepping strategy.

We have identified a number of key balance progressions and the importance of moderate to high intensities to make balance improvements and reduce fall risk with our older adults. So why aren’t all clinicians doing it? Because it’s hard!

We have to constantly analyze and reassess our patients’ abilities and inspire them to see the value in what we can offer.

Like me, I’m sure you have patients who don’t quite understand the value of balance training despite education. Also, older adults are likely to be more complex. Personally, I treat many older adults who have multiple comorbidities, psychological disorders (like depression and anxiety), recurrent urinary tract infections, or severely impaired cognition.

However, research is backing us up to say the hard work is worth it! Your patients are 25 percent less likely to fall by doing specific balance interventions at moderate to high intensities 3 hours per week.

EXPECTATIONS VERSUS REALITY OF FALL REDUCTION INTERVENTIONS

We need to be prescribing the appropriate interventions with a high level of intensity to help prevent future falls. If our patients do not see the value in our treatments and do not see how we are directly impacting their lives on a daily basis, we should take a closer look on what is meaningful to them and start there.

So let’s get creative, dig deep, and make a change. As Thomas Edison once said: “When you have exhausted all possibilities, remember this: You haven’t.”