By Leigh E. Whitton, PT, DPT
Falls are the number one cause of injuries, fatal and non-fatal, in older Americans.1 Falls threaten the safety and independence of seniors and generate enormous economic and personal costs. Though fall incidence increases with advancing age, it is not an expected age-related change. According to the Centers for Disease Control and Prevention, more than one in four older adults fall each year and one out of five falls cause serious injury.1,2 The risks for falls are varied and include physiologic, medical, environmental, and emotional factors. The foremost predictor of a fall is history of a previous fall, which doubles the risk of subsequent falls.3
Many people who fall, whether injured or not, develop an intensified fear of falling. With this heightened level of anxiety, individuals often decrease their potential exposure and reduce everyday activity, leading to diminished strength and balance, which further increases an individual’s risk for a fall.4 We also see that a fall with injury can begin a detrimental medical sequela, which is one of the reasons that falls are a leading cause of morbidity and mortality in the elderly population. Therefore, fall reduction and prevention programs are vital to minimizing fall incidence and its impact on the healthcare system.
Reducing Risk, Building Balance
Physical therapists have a wealth of knowledge and skills to offer when it comes to fall reduction. Understanding the interplay of musculoskeletal, neuromuscular, medical, environmental, and psychological factors involved in physical fitness and health is imperative to the implementation of a successful balance retraining program. Through thorough examination, a physical therapist works to identify the root of an individual’s fall history and determines future fall risk. From the assessment of lower extremity and core strength, righting reactions, gait deviations, sensation, sensory integration ability, vestibular function, and coordination, a therapist can build a balance retraining plan that is patient specific and effective.
There are numerous reliable and valid clinical tests that can be performed to quantify fall risk. Some of these include the Timed Up and Go, gait speed, BERG Balance Scale, BESTest, Dynamic Gait Index, Tinetti Gait & Balance Assessment, Functional Reach, Fullerton Advanced Balance Scale, and the modified Clinical Test of Sensory Integration for Balance.5 These tests can be performed quickly in the clinic, have high inter- and intra-rater reliability, and require little to no equipment to perform. They also provide objective measures that quantify an individual’s risk for falls and can provide areas to focus on when developing a plan of care.
The following companies provide technologies directed at preventing falls as well as the recovery of gait and balance:
Accelerated Care Plus
Allard USA Inc
Clarke Health Care Products
GAITRite/CIR Systems Inc
Gorbel Inc-Medical Division/SafeGait
Natus Balance & Mobility
Applying Technology To Fall Prevention
Several therapy technologies also exist that can be used to more fully assess a patient’s balance function and allow for advanced training programs. The NeuroCom Balance Master Systems developed by Natus Medical Inc, San Carlos, Calif, offer a variety of diagnostic and therapeutic options. The SMART Balance Master line from Natus performs Computerized Dynamic Posturography, including the Sensory Organization Test and Adaptation Tests to identify balance impairments related to sensory deficiency (visual, somatosensory, and/or vestibular). This system, used frequently for research purposes and in university clinics, utilizes a dynamic force plate with rotation capability to quantify the vertical forces exerted through the feet, measuring center-of-gravity position and postural control. It also has a dynamic visual surround to measure an individual’s utilization of and reliance on visual information for balance. These assessment capabilities are useful for impairment identification and subsequent plan of care development. The NeuroCom system has an overhead body weight support harness to ensure safety and can be used for training with visual biofeedback on either a stable or unstable support surface and in a stable or dynamic visual environment. It has been shown that the test-retest reliability of the Balance Master is greatest for complex balance tests and that dynamic testing is a valid indicator of functional balance performance.6
A similar, smaller-scale system is the Balance System SD from Biodex Medical Systems, Shirley, NY. This product features intuitive operation with a touch-screen monitor, a force plate with rotational motion, and supplemental dynamic balance padding. It has a number of testing protocols and training modes in both static and dynamic formats. In the testing mode, it assesses center of gravity position, limits of stability, and will perform sensory integration balance testing with a modified Balance Error Scoring System (BESS) test and the Clinical Test of Sensory Integration for Balance (CTSIB).7 In the training mode, it provides closed-chain, weight bearing balance tasks that enhance kinesthetic awareness and balance reactions. This device allows clinicians to assess neuromuscular control by quantifying the patient’s ability to maintain bilateral and unilateral postural stability on a static or dynamic surface. For advanced training, it also offers games such as a ball toss game with audio and visual feedback. Utilization of this product is simple, takes little setup for the patient or therapist, and encourages patient engagement with the various training programs and games. This system can be combined with an overhead body weight support system, which allows for increased patient independence and, in turn, increases the patient’s balance confidence.
Body Weight Support Adds Safety
As previously mentioned, an overhead body weight support harness can be a helpful way to increase patient safety and allow for more targeted or decreased facilitation from the therapist. With a variety of systems on the market, there are many options depending on the needs of the clinic.
One popular system is the LiteGait Partial Body Weight Support System from Mobility Research, Tempe, Ariz, which is compact, mobile and can be used for over-ground and over-treadmill gait training with an electronic, remote operated lift. It has many benefits for gait training and early standing support, though it may not be specifically indicated for higher-level balance training.
Another overhead system is the FreeStep SAS—Supported Ambulation System from Biodex. This system attaches to either a static or moveable overhead track system. It has more infrastructure requirement with increased adaptability compared to many other options. The FreeStep can support up to 750 pounds and can be used for early standing and gait training with extremely weak patients. When used for high-level balance training, this system has a wide range of versatility. The FreeStep SAS allows for movement in 360 degrees of motion and is operated by a pulley system that allows the therapist to control the amount of tension and quickly change the direction and height of support. It can be used during functional training, such as sit to stand, stairs, instrumental activities of daily living, and even floor recovery. The FreeStep trains for reactive postural control, allowing the patient to engage all strategies (ankle, hip, and step) for balance reactions without therapist intervention. This system requires less staff for guarding during unstable activities and can even be used concurrently by multiple patients. Most importantly, this system, and others like it, minimizes the fear of falling that can limit patient effort and stunt balance retraining.
Digital Technologies for Integrated Therapy
There are numerous neuro-retraining devices on the market that can be beneficial in balance programs. Of the many systems available, finding challenges that are vibrant and engaging is vital to maximizing patient participation. The Nintendo Wii Fit is a great example of a fun and interactive product that incorporates competition into balance training. Another such system of note is the Bioness Integrated Therapy System (BITS). This product includes a large touch screen television that is height adjustable and can be easily maneuvered throughout the clinic. It offers more than 20 interactive training options and assessments that focus on several domains including hand-eye coordination, dual attention tasks, memory and recall, and visual search and scanning. This system can be used to work on a number of impairments, and the setup of the device is quite useful when used as part of a balance retraining regimen. It allows patients to work on cognitive skills, vestibular challenges, and coordination tasks while having the patient set up in a position to challenge balance at the same time. These types of “gaming” systems are wonderful at keeping patients motivated and making training feel more like “play” than work.
Balance Training Basics: Still Effective
It is important to note that balance training and fall prevention programs can be implemented in a variety of ways. If space or funding is limited, individualized balance training can be successfully achieved with inexpensive items such as pillows, folded blankets, balls, obstacle courses, or cones; the only limit is the imagination. Working on static balance (double and single leg), ankle and pelvic stability, righting reactions, lower extremity strength, dynamic balance, increased utilization of sensory input (particularly vestibular), and gait training are some of the keys to fall prevention. Typical clinic equipment like the Balance Pad from Airex AG, Sins, Switzerland, and the Balance Trainer from BOSU, Ashland, Ohio, can be combined with traditional exercises or advanced technology to modulate the level of challenge. Similarly, basic products like wobble boards, therapy balls, Dynadiscs, therapy bands, and step stools can be used to create a challenging exercise program or serve as adjuncts to balance retraining technology. Lastly, incorporating techniques from tai chi and yoga can also be extremely beneficial for treating impairments and helping patients transition into community-based exercise programs with continued balance practice. The primary focus, with or without sophisticated equipment, should always be on addressing fall risks and increasing an individual’s balance confidence to keep seniors as active as they want to be. If we, as physicals therapists, do our part to increase the community activity and involvement of our patients, then the simple act of staying active will help to minimize the risk for future falls. PTP
Leigh E. Whitton, PT, DPT, is a physical therapist, Stroke Program Champion, and Center Coordinator of Clinical Education at HealthSouth Rehabilitation Hospital of Newnan in Newnan, Ga. She has a specialty in Vestibular Rehabilitation, is a certified LSVT BIG clinician, and a Level I Tai Chi Instructor. Leigh earned her bachelor’s degree in chemistry from the University of West Georgia and her Doctor of Physical Therapy from Emory University. For more information, contact PTPEditor@medqor.com.
1. Alexander BH, Rivara FP, Wolf ME. The cost and frequency of hospitalization for fall-related injuries in older adults. Am J Public Health. 1992;82(7):1020-3.
2. Sterling DA, O’Connor JA, Bonadies J. Geriatric falls: injury severity is high and disproportionate to mechanism. J Trauma. 2001;50(1):116-9.
3. O’Loughlin J, Robitaille Y, Boivin JF, Suissa S. Incidence of and risk factors for falls and injurious falls among the community-dwelling elderly. Am J Epidemiol. 1993;137:342-54.
4. Vellas BJ, Wayne SJ, Romero LJ, Baumgartner RN, Garry PJ. Fear of falling and restriction of mobility in elderly fallers. Age Ageing. 1997;26:189-193.
5. Shumway-Cook A, Baldwin M, Polissar NL, Gruber W. Predicting probability for falls in community-dwelling older adults. Phys Ther. 1997;77(8):812-819.
6. Liston RA, Brouwer BJ. Reliability and validity of measures obtained from stroke patients using the Balance Master. Arch Phys Med Rehabil. 1996;77(5):425-430.
7. Shumway-Cook A, Horak FB. Assessing the Influence of Sensory Interaction on Balance Suggestion from the Field. Phys Ther. 1986;66(10):1548-1550.
Patient Fear Holds Back Progress and Outcomes
Fear plays a major role in the lack of progress in the recovery of patients who have suffered a fall, traumatic accident, or stroke. Therapists can face a unique challenge treating these types of patients in addressing their fear and anxiety. Developing an atmosphere of trust between therapist and patient is critical in moving forward with their treatment plan.
For a healthy human being, normal movements and actions are often taken for granted. However, when a patient experiences a traumatic accident—or encounters a disease process such as a stroke—the results can severely impact movement. In some cases fear and/or anxiety may affect the patient, dramatically slowing recovery and limiting the ability to return to a prior level of function.
The less fearful a patient is, the more that individual is willing to cooperate with a therapist. One approach for offsetting patient fear is to engender a sense of safety and comfort in the patient. For this approach to be effective, the equipment used in rehabilitation plays a vital role. If old equipment and equipment in disrepair is all that is available, the therapist is at a tremendous disadvantage. Such equipment will not provide the safety and comfort the patient and therapist deserve, and the perceived benefits of safety and comfort will be missed.
The contribution that safety and comfort make in the rehabilitation process is significant. For example, in many instances a patient can physically perform a task requested by a therapist. Fear, however, may keep the patient from attempting the task. Likewise, if an accident caused by unreliable or inappropriate equipment results in injury to the patient or therapist, the incident may undo any progress regardless of how effective a rehabilitation technique may be.
Another factor contributing to patient fear is an unfamiliar routine. Transferring patients from one apparatus to another can be stressful. Studies show that most injuries occur to patient and therapist during a transfer. Eliminating unnecessary transfers and creating familiarity and routine with patients can greatly reduce their fear and anxiety, thereby contributing to faster recovery and better outcomes.
Clemente Aquino, Jr, OTR, is vice president, Rehab Practice Standards, Life Care Centers of America.
Frank Long is editorial director of Physical Therapy Products. For more information, contact PTPEditor@medqor.com.
Objective Measures of Gait and Balance Help Researchers Identify Fall Risk Factors
By Frank Long, Editorial Director
The medical literature is conclusive: growing older means an increased risk of falling. Regardless of whether an older adult is active or inactive, changes in the systems that control balance occur over time among large numbers of seniors.1 In fact, among community-residing adults age 65 years and older, one-third will record a fall each year.2
Despite the physiological changes that can contribute to falls, there are ways to develop a clearer picture of an individual’s fall risk level. Clinical technologies have been developed that can be used to help predict the risk of falling by generating quantitative measures of gait and balance. These systems are designed to gather measures with relative speed and ease of use, without requiring extensive training. They are offered by manufacturers as office-based installations as well as portable models.
One technology that can provide these measures is instrumented walkways. One such device, the GAITRite, from CIR Systems Inc, Franklin, NJ, was used to help researchers determine that, among older adults, quantitative gait markers are independent predictors of falls.3 The GAITRite, embedded with pressure sensors that provide exportable footfall, gait cycle, walk, and test-level measurements, was used to assess study subjects walking with and without assistive devices. The device was used to measure markers that had predictive adverse outcomes: gait speed, stride length, cadence, swing phase, double-support phase, stride length variability, and swing time variability. Data gathered by this technology helped the study authors conclude that the gait variables they identified as potentially modifiable factors could be applied to training or pharmacological interventions.3
In a separate study recently published, functional gait measures provided critical data about the effectiveness of dual-task functional power training for preventing falls among older adults.4 For this study researchers assessed gait function using a Zeno Electronic Walkway System, available from Havertown, Pa-based company ProtoKinetics. The system comprises a computerized walkway and PKMAS software. The walkway includes a 16-level sensing pad that has 18,432 pressure sensors arranged in a grid pattern. The study subjects performed 18 trials on this system, and the Zeno Electronic Walkway System provided the researchers with gait parameters for gait velocity (meters per second), cadence (steps per minute), step length (centimeters), double support time (seconds), and stride width (centimeters). Study results were aimed at developing community-based fall prevention programs for older adults.
1. Rogers ME, Page P, Takeshima N. Balance training for the older athlete. Int J Sports Phys Ther. 2013;8(4):517-530.
2. Sattin RW. Falls among older persons: a public health perspective. Annu Rev Public Health. 1992;13:489-508.
3. Verghese J, Holtzer R, Lipton RB, Wang C. Quantitative gait markers and incident fall risk in older adults. J Gerontol A Biol Sci Med Sci. 2009;64(8):896-901.
4. Daly RM, Duckham RL, Tait JL, et al. Effectiveness of dual-task functional power training for preventing falls in older people: study protocol for a cluster randomized controlled trial. Trials. 2015;16:120.