Proper screening and assessment, as well as the proper exercise prescription, can help reduce the risk of falls for older adults

By Louis DePasquale, PT, MA


Falls remain an urgent public health concern, increasing in magnitude with the Baby Boomer demographic, which is rapidly growing and aging. Older adults sustaining a prior fall are three times more likely to experience another fall within a 12-month period compared to those without a prior fall. Falls occur commonly among older people who have no apparent balance deficits, as well as those with visible or easily detected impairments, representing the number one cause of non-fatal injurious trauma and the leading cause of emergency department visits, hospital admissions, and injurious death.

The aftermath of an injurious fall stresses the healthcare system, frequently initiating a downward functional mobility spiral. Fall prevention/risk reduction is a primary focus of healthcare agendas incorporating development and implementation of comprehensive assessment tools and evidence-based multifactorial interventions. The need for early identification of heightened fall risk in community-living older adults is imperative to achieve a decrease in fall rate, injury, and death attributable to falls.1,2,3


Despite the lack of consensus, falls are usually defined in the literature as any unintentional loss of balance during routine activities resulting in contact with the ground or a lateral lower level. Acute medical events and extreme environmental causes typically are excluded.

A fall reporting scale, the 4-Point Hopkins Falls grading Scale (HFGS), was developed and validated: Grade 1, near fall slip or trip no ground contact; Grade 2, fall to ground or lower level no medical attention; Grade 3, fall medical attention no hospitalization; Grade 4, fall and hospitalization.4

Fall Risk Factors

Intrinsic non-modifiable: age, gender, race, and chronic disease.

Intrinsic modifiable: acute illness, incontinence, fall history, gait/mobility impairments, visual/sensory deficits.

Extrinsic modifiable: medications-polypharmacy/side effects, home hazards, footwear, behavior.6


Age-related changes include: impairments in somato-sensory and mechanical receptor responsiveness and vestibular mediated visual and sensory integration deficits, causing dizziness and unsteadiness; slower nerve conduction velocity; decreased response amplitude; increased reaction time, muscle response latency, postural sway velocity, and anterior-posterior sway. These factors may negatively impact safety, body position awareness, and responses to perturbation,7,8 increased stride width, reduced gait speed, stride-to-stride variability, and gait path deviation.

Age-related changes in physical fitness include loss of 20% to 40% maximal strength by age 65 years in sedentary adults; decreased ankle dorsiflexion power, hip strength, and knee extensor strength are associated with falls in older adults.10 Other modifiable age-related changes possibly associated with higher fall risk include: reduced lung volume and capacity; reduced cardiac output; increased systolic blood pressure and peripheral resistance; prolonged recovery time with relative greater work rate during physical activity; increased reliance on anaerobic metabolism; and reduced flexibility due to decreased elastin and increased collagen muscle tissue. Available data in general indicates an inverse relationship between physical fitness and falls.6

AGS Guidelines

Revised American Geriatrics Society (AGS) guidelines specify for individuals 65 years of age and older an expanded annual fall risk screening and assessment to include fall history, balance, and gait assessment, with a comprehensive multifactorial fall risk assessment performed by a skilled trained clinician in the presence of positive balance/gait findings. AGS guidelines recommend individuals reporting a single fall, demonstrating negative gait/balance findings do not require a multifactorial assessment.11 Considering it takes only one fall to produce deleterious effects, it may not be appropriate to recommend “no intervention” as an option when addressing the public health importance of preventing falls in older adults. People with modifiable risk factors without a prior fall will benefit from treatment.12

Comprehensive Fall Risk Assessment 

Components: Relevant history, physical exam, cognitive and functional assessment, fall history, medication review, gait, balance, mobility assessment, visual acuity, neurologic impairments, muscle strength, heart rate and rhythm, postural hypotension, feet and footwear, environmental hazards.2

AGS Evidence-Based Level A and Level B Recommended Interventions

Home modifications; reduction of psychoactive medications; balance, strength, flexibility, endurance and gait training exercise; management of postural hypotension; reduction in poly-pharmacy.11

Performance Components of Balance and Fall Risk

The primary objective of a falls prevention intervention program is to identify persons at risk of falling. Clinical tests and measures must discriminate between groups, predict a result or expected outcome, and evaluate change over time. In selecting a screening tool, various aspects must be taken into consideration, including: sensitivity, specificity, reliability, clinical feasibility (cost, time, space), validating populations, meaningfulness of findings, and limitations of the instrument.

Effective and efficient static and dynamic postural control is context specific, involving reactive and proactive balance/postural responses.

Proposed balance elements include: biomechanical constraints, stability limits, transition/anticipatory postural adjustment, reactive postural response, sensory orientation, and gait stability.12 Measures of balance for the community-living older adult should be more challenging, more discriminating, and include items of greater task and environmental complexity to better replicate postural demands in real-world environments.14

Fall Risk Screening and Assessment: Evidence-Based Tools 


Tools for this type of testing include Semmes-Weinstein mono-filament testing (tactile sensitivity); tuning fork (vibration); Snellen eye test (visual acuity, static/dynamic); and Melbourne edge test (contrast sensitivity PAP component). Other available tools include the RealEyes x DVR, from Chatham, Ill-based Micromedical Technologies Inc. This is a VNG tool that can perform Dix-Hallpike/horizontal canal (BPPV) testing.

Modified Clinical Test of Sensory Interaction on Balance (MCTSIB) is another useful tool in somato-sensory testing, as well as Airex Balance Pads, which are available from Fitter International Inc, Calgary, Alberta, Canada. Also used is the sensory organization test (SOT), which can be performed by EquiTest, available from Clackamas, Ore-based NeuroCom International Inc. Frailties and Injuries: Cooperative Studies of Intervention Techniques–4, (FICSIT-4); and Dynamic balance assessment (DBA) can also be used for testing.

Physical Function

Assessments for physical function include computerized dynamic posturography, which can be performed by NeuroCom International Inc’s Smart EquiTest, as well as Micromedical Technology Inc’s Balance Quest. Computerized gait assessment can be performed by the GAITRite, from CIR Systems Inc, Sparta, NJ, or the Zeno Walkway from ProtoKinetics, Havertown, Pa. Limits of Stability can be tested with force platform technology such as the MatScan with Sway Analysis, offered by Boston-based TekScan Inc. Accelerometry Movement Analysis, which can be performed by the Mobility Lab, from Portland, Ore-headquartered APDM Inc, is also useful for this type of assessment.

Other types of physical function testing include TUGT; BBS; DGIm; Functional gait assessment (FGA); Tinetti POMA; 4 square step test (4SST); 5 times stand sit test (5XSST); Fullerton Advanced balance Scale (FAB); Functional Gait Assessment (FGA); BRIEF-BESTest; Short physical performance battery (SPPB), Voluntary Step Execution Test, Community Balance and Mobility Scale (CB&M), Walking and Remembering Test (WART); Sit and Reach Test, (Leighton Flexometer Inc, Spokane, Wash).


The following tools are designed as questionnaires, and aim to assess components of fear or activity restriction.

Fall Risk Assessment & Screening Tool (FRAST), Modified Falls Efficacy Scale, (mFES), Modified Gait Efficacy Scale (mGES), Activities-Specific Balance Confidence short version (ABC-6), Fear of Falling Avoidance Behavior Questionnaire (FFABQ), Survey of Activities and Fear of Falling in the Elderly (SAFE), Physical Functioning Scale of the Short-Form (SF) 36.

Evidence-Based Interventions

Prior to exercise, all fall risk factors should be assessed and triaged appropriately. Exercise interventions should be structured and progressive, tailored to the specific needs of the individual, and achieve optimal dose. Recommendations differ for frail institutionalized and non-frail community-living groups.2


Evidence suggests for community-living older adults, recommended exercise dose is to be 50 hours over a period of 3 to 6 months.2


Moderate to high challenge balance training has been reported to be the only mode of exercise that had significant protective effect on the rates of falls (estimated 25% reduction). Other evidence-based modes of exercise include: strengthening, stretching, dynamic gait training, dual-task training, walking, integration, perturbation, and compensatory stepping.2

Adaptation to repeated perturbations and stepping responses for the purposes of fall risk identification and development of balance intervention strategies in healthy and impaired older adults has received recent interest.15-23 Postural reaction time is a strong determinant of falls risk.21 Strong associations between tether-release stepping recovery responses and biomechanical parameters such as step length, step timing, and joint torques point to the importance of neuromuscular capacities that relate to lower-extremity flexibility, reaction time, and strength. The maintenance or enhancement of these core attributes should be considered when developing exercise-based fall intervention programs for older adults.

Original work by DePasquale and Toscano22 provides the evidence-based foundations of the RIPPS Balance Method, offered by GNR Health Systems Inc. RIPPS (Repeated Incremental Predictable Perturbations) is a highly discriminant, reactive/proactive perturbation clinical tool validated on community-living older adults. The RIPPS percent of total body weight (% TBW) clinical performance measure quantifies stepping frequencies and responses at threshold % TBW, 10% TBW, and limit % TBW milestones for purposes of fall risk assessment and induced-stepping intervention.

The RIPPS 10% TBW performance value was most discriminant to fall status compared to four other measures examined. RIPPS intervention goals include increased threshold and directional limit stepping % TBW force, and/or reduced number of steps required to maintain effective balance at RIPPS measurement milestones, with the net effect of development of quicker postural responses with enhanced adaptation to repeated 

Exercise Mode Specific Tools


Products that can be helpful for stretching regimens used as part of a fall-prevention strategy include the Flexometer, Acuflex I, and adjustable slant boards from Warminster, Pa-headquartered Stretchwell. Other useful products in this category include Prostretch, looped stretch straps available from Minneapolis-based OPTP, and Kyphosis/forward head reduction management, lumbar roll /cushion, also available from OPTP.


Several devices offer good utility for building strength among individuals who are at risk for falls. Among these technologies are the Eccentron, manufactured by BTE, headquartered in Hanover, Md; the NuStep T4r, offered by NuStep, Ann Arbor, Mich; and ResQup, available from Safe Patient Solutions, Prescott Valley, Ariz. Elastic tubing and bands from Akron, Ohio-based Hygenic Corporation may also be useful in this application.


Many useful technologies for building balance are on the market, and can be helpful in fall prevention. Stoughton, Mass-headquartered CSMi offers the HUMAC Balance System, while Med-Fit Systems Inc, Fallbrook, Calif, provides the Korebalance Premiere.


RIPPS Balance Method is designed to work well with perturbation training.


BalanceWear by the California-based company Motion Therapeutics is an evidence-based, proprioceptive, neuromuscular strategic weighting body torso device, developed by a physical therapist.22

Other products helpful for walking include GaitRite, from CIR Systems Inc, the Bungee Trainer from NeuroGym Technologies, Ontario, Canada, and the ZeroG Gait and Balance Training System, from Aretech LLC.


Thoughtful selection of measures, appropriate for the target population, clinically feasible, and psychometrically sound, for assessing physical function of community-living older adults and frail older adults, is an essential step along a path toward evidence-based practice in geriatric physical therapy. PTP

Louis DePasquale, PT, MA, is a physical therapist at Bon Secours/Schervier Health System serving as geriatric clinical consultant/balance specialist. DePasquale has more than 30 years’ experience in geriatric care, authored several peer-reviewed publications, and has presented nationally about objective geriatric balance and fall assessment. He is a member of the APTA’s Sections on Geriatrics and Home Care. For more information, contact [email protected]