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

www.legacy.com
www.musselfit.com