Balance and Fall Balance and Fall PreventionPrevention

Michael Haberpointner, PT, DPT

Doctor of Physical Therapy

Active Life Physical Therapy, LLC

Port Ludlow, WAOctober 2011

Balance and Fall PreventionTwo part lecture

1) How our balance system works

2) What you can do to prevent falls

Falls Falls

• 1/3 of people over 65 fall each year5,6

• Most common cause of injury death for 65+ 2

• 90% of hip fractures in older adults10

• Most common cause of non-fatal injuries2

Vicious CycleVicious Cycle

Fall

↗ ↘

Imbalance ←Inactive

Balance DefinedBalance Defined• Balance: Control of center of mass

over base of support (Shumway – Cook, 2001)14

• Center of mass: Center point of each body segment combined

• Center of gravity: Vertical projection of center of mass

• Base of support: Area of object that is in contact with the ground

Base of SupportBase of Support

Center of MassCenter of Mass

Balance: Control of center of mass over base of support

Balance: control of center of Balance: control of center of mass over base of supportmass over base of support

Cane widens base of Cane widens base of supportsupport

Types of BalanceTypes of Balance• Steady state (static) balance:

Maintain stable position in standing or sitting

• Reactive balance: Recovering from an unexpected perturbation

• Proactive (anticipatory) balance: Activating balance in advance

Types of BalanceTypes of BalanceReactive balance (being nudged by

someone)

Reactive BalanceReactive Balance

Types of BalanceTypes of Balance

Proactive (anticipatory) balance: Reaching, leaning, pulling

Balance SystemsBalance Systems

Balance is a complex composite of multiple body systems

Motor

Sensory

Cognition

Motor SystemsMotor SystemsMusculoskeletal system: strength

and flexibility

Neuromuscular system: coordination of movement

Sensory SystemsSensory Systems

Peripheral input: Visual, vestibular (inner ear), somatosensory (input from joint and muscle receptors, auditory (hearing)

Central processing: Receives information from periphery interprets it, and sends commands to motor systems

CognitionCognition

Multitasking and filtering out distractions while maintaining balance

Sensory components of Sensory components of balancebalance

• Vision: Significant portion of balance is dependent on vision. If we close our eyes, we become reliant on our inner ear and somatosensory (body) systems.

• Somatosensory: What you body is telling you. Receptors in your joints and muscles are receiving information of where your body is in space.

VisionVision

SomatosensorySomatosensory

Sensory components of Sensory components of balancebalance

Vestibular system (inner ear): Semicircular canals oriented in 3 different planes.

Vestibular system: Head movement displaces fluid on hair cells within canals which excites the vestibular nerve.

Auditory system: Small component of balance (e.g. walking in a sound-proof room)

Inner earInner ear

Inner earInner ear

Body response to sensory Body response to sensory inputinput

Normal body response to perturbation(pushing patient forward and back)

A)Mild perturbation: Ankle response (push patient forward, the calf muscles engage)

B)Moderate perturbation: Hip response (push patient forward, patient leans back)

C)Large perturbation: Stepping response (patient steps forward to avoid falling)

Ankle responseAnkle response

Dynamic Balance—Gait Dynamic Balance—Gait AnalysisAnalysisBalance during gait is different

than static balance. The center of gravity does not stay within the base of support. The body is in a constant state of imbalance.

Once a step is initiated, gait is

sustained by momentum.

Gait CycleGait Cycle

Age related changes to Age related changes to motor components of motor components of

balancebalance

Decreased magnitude of muscle response

Increased reliance of arms

Age related changes to Age related changes to sensory components of sensory components of

balancebalance

Decreased visual, vestibular, somatosensory (body awareness), and auditory (hearing) function

Decreased ability to adapt responses (e.g. using your inner ear and your feet

Walking on beach at nightWalking on beach at night

Age related changes to Age related changes to cognitive components of cognitive components of

balancebalanceDecreased overall attention

capacity Decreased ability to multitask

(e.g. carrying a cup of water while walking)

Abnormal balanceAbnormal balanceAs the balance system declines,

so does the ability of the system to respond correctly

Individuals with an increased fall rate did not use an ankle strategy 2

Abnormal balanceAbnormal balanceCerebrovascular accident (CVA)—

Stroke

A) Synergistic pattern: Groups of muscles work together in a “stuck” pattern

B) Increased muscle tone

C) Cognition (e.g. impulsive behavior)

D) Impaired body awareness

Abnormal balanceAbnormal balance

Parkinson’s DiseaseA) Dynamic balance problem

B) Difficulty initiating gait

C) Moments of freezing during movement

D) Altered gait cycle

Abnormal balanceAbnormal balanceBenign Paroxysmal Positional Vertigo

(BPPV)

A) Calcium crystals stuck in the semicircular canals in the inner ear.

B) Dependent on head position.

C) Vertigo –sensation that the room is spinning.

Inner earInner ear

Abnormal balance Abnormal balance

Orthopedic cases: (Hip or knee replacement)

A) Impaired joint range of motion (alters center of mass during gait and stance)

B) Altered body awareness (new body part)

Balance testsBalance testsBerg Balance scale: Discriminates older adults at risk for

falls 14

Single best predictor of fall status in community dwelling adults

Sound test with good reliability

Mainly tests static and anticipatory balance

Berg Balance ScaleBerg Balance ScaleSitting to standingStanding unsupportedStanding to sittingStanding unsupported with eyes closedStanding unsupported with feet togetherReaching forward with outstretched armPick up object from floorTurning to look over right and left shoulderTurn 360 dgStep on step stool (# times in 20 seconds)Tandem stance; Standing on one foot

Balance Tests – Berg Balance Balance Tests – Berg Balance ScaleScale14 item scale for possible 56 points total

• Decrease in Berg score = increased fall risk14

• Score of 56-54, 1 point drop = 3-4% inc. fall risk

• Each point drop from 54-46, = 6-8% increase

• Below 36, fall risk = 100%

• Limitations: does not test reactive balance; ceiling effect

Balance TestsBalance TestsTimed up and go test12

• Get up from seated position, walk 3 meters, turn around, walk back to chair

• Adults who took > 30 sec were dependent in activities of daily living

Functional reach test• Standing reaching forward with hand• Highly predictive of falls among older

adults3

Functional Reach TestFunctional Reach Test

Balance TestsBalance TestsNudge test:• Moving patient forward, back, sideways

• Ankle vs hip, vs stepping strategy

• Test under different conditions: soft surface, eyes closed, with head movements

Other tests: • Hallpike - Dix (testing for vertigo),

observational gait analysis, dynamic gait index

Balance TestsBalance Tests

Treatment of Balance Treatment of Balance

Restoring ankle function and muscle facilitation with electrical stimulation

Restore normal ankle response

Nintendo Wii fit—balance training system

Gait training

Treatment – Shin Treatment – Shin StimulationStimulation

Nintendo Wii Fit SystemNintendo Wii Fit System

Treatment of balanceTreatment of balance

Exercise examplesA) Calf stretch

B) Heel / toe raises

D) Soft surface stance in corner

E) Sitting to standing

Summary of Balance Summary of Balance SystemsSystemsEvaluation to Treatment

Falls Falls 1/3 of people over 65 fall each year5,6

In 2008, 82% of fall deaths people 65+2

Average hospitalization cost $17,500.1013

By 2020, annual direct & indirect cost of fall injuries is expected $54.9 billion4

Vicious CycleVicious Cycle

Fall

↗ ↘

Imbalance ←Inactive

Fall PreventionFall PreventionPlease pick up packet “What you

can do to prevent falls” by the Centers for Disease Control and Prevention.

1)Begin a regular exercise program2)Have your doctor review your

medicines3)Have your vision checked4)Make your home safer

Falls Risk FactorsFalls Risk Factors

Risk factor: puts you at risk for falling

Intrinsic risk factors + extrinsic risk factors = FALLS

(Clare Morrison, MCSPT 2006)

Intrinsic Risk FactorsIntrinsic Risk FactorsWithin the individual• Age• Being female or male• Previous fall• Impaired balance• Lower body weakness• Taking more than 4 medications• Neuropathy; more than one

chronic disease

Extrinsic Risk FactorsExtrinsic Risk Factors

Person’s environment: Uneven surfacesObstacles, stairs, curbsPoor lighting, sudden changes in

lightingSlippery surfacesPoor footwearPoorly fitted assistive devices for

walking

Extrinsic Risk FactorsExtrinsic Risk Factors

Falls Risk FactorsFalls Risk Factors

Cognition / Mental HealthDepressionAnxietyCognitive impairments / Dementia

*One or more of the above increases fall risk.

Sally York, MN, RNC 2006

Modifiable Risk FactorsModifiable Risk FactorsRisk factors you can change

Lower body weakness

Gait problems

Impaired gait (walking)

Taking > 4 medications

Non Modifiable Risk Non Modifiable Risk FactorsFactorsRisk factors you cannot change

AgeSexHistory of fallsDisease state

Most Common Falls Risk Most Common Falls Risk FactorsFactors

According to U.S. Department of Health and Human Services

1) Muscle weakness *2) History of falls3) Gait deficit *

*modifiable risk factors

Falls Risk FactorsFalls Risk Factors

Risk of falls dramatically inc. as thenumber of risk factors inc. (Tinetti

2003)15

8% in older adults with no risk factors

78% in older adults with 4 or more risk factors

Senior Falls Prevention Senior Falls Prevention StudyStudy

WA Department of Health Study (2006) key findings

Older adults are often unaware of their health, medications, and overall risk of falling.

It takes a fall for an older adult to be concerned about falls.

Health care providers “don’t ask” and older adults “don’t tell” about falls.

Senior Falls Prevention Senior Falls Prevention StudyStudy

Senior Falls Prevention Senior Falls Prevention StudyStudyWA DOH Study (2006) continued:

Older adults will reduce modifiable risk factors if they get information from their health care provider and if they have access to fall prevention information.

What You Can Do To Prevent What You Can Do To Prevent FallsFalls1)Begin a regular exercise

program2)Have your doctor review your

medicines3)Have your vision checked4)Make your home safer

1. Start a Regular Exercise 1. Start a Regular Exercise ProgramProgram

U.S Surgeon General’s Recommendation30 min / day (break it up 10 min per

session) 6 days of the week.Moderate intensity activity / weekExamples of moderate intensity activityGardening 25 min, Walk 2 miles in 30

minSwimming laps or water aerobics for 20

min**Start slow. Something is better than

nothing.

1. Start a Regular Exercise 1. Start a Regular Exercise ProgramProgram

Start a Regular Exercise Start a Regular Exercise ProgramProgramModerate intensity: You can still carry

on a conversation while you exerciseStart at a slow pace: 5-10 minutes a

dayWear sturdy shoesDrink plenty of waterWalking indoors (mall) or w/ a friendStop exercising if you experience

shortness of breath, chest pain, dizziness

1. Start a Regular Exercise 1. Start a Regular Exercise ProgramProgram

Start a Regular Exercise Start a Regular Exercise ProgramProgram

Key Components of exercise program

1)Endurance

2) Strength ≥ 2x per week

3) Balance ≥ 2x per week

4) Flexibility

Start a Regular Exercise Start a Regular Exercise ProgramProgram

Strengthening guidelines: No pain during exercise

Normal: muscle soreness & mild fatigue

Slow, steady movements

Do not hold breath (breathe out with effort and in as you relax)

Start a Regular Exercise Start a Regular Exercise ProgramProgram

Balance exercise guidelines:

Safely: Your back to a corner & chair in front

Someone present

Go slow. If dizzy sit down

Start a Regular Exercise Start a Regular Exercise ProgramProgram

Start a Regular Exercise Start a Regular Exercise ProgramProgram

Stretching guidelines:

Slowly get into positionGentle, hold stretch for 15-20

secondsAvoid bouncing movements

*check with PT what exercise is appropriate for you. Everyone is different.

Have Your Medications Have Your Medications ReviewedReviewed

2. Have your Medications 2. Have your Medications ReviewedReviewed

Older adults who take 4 or more meds are at increased risk of falling16

Aging and new health conditions can change how medications affect you

Medication problems can happen easily in adults who have difficulty paying for meds

People living alone can have med problems

Have Your Medications Have Your Medications ReviewedReviewed

Medication safety rules (WA State DOH)

Keep current, dated list of ALL meds w/ you

Follow instructions for taking meds

Read and keep a copy of prescription info

Create a system and regular routine

2. Have your Medications 2. Have your Medications ReviewedReviewedMedication safety rules (WA state DOH)

Provide complete medical history to provider

Provide complete list of ALL meds

Tell your provider how you usually take meds

Discuss concerns about medication cost

Ask what the meds are for & side effects

Take notes

2. Have your Medications 2. Have your Medications ReviewedReviewed

Get your prescriptions filled at the same pharmacy. This allows pharmacist to identify potentially dangerous drug interactions.

Think teamwork: Your Doctor, Physician Assistant, Nurse Practitioner, Pharmacist, Hospital Staff, and You.

3. Have Your Vision 3. Have Your Vision CheckedCheckedHave your vision checked by an eye doctor at least once a year

Poor vision can increase your fall risk

Check with local Area of Aging for vision care assistance program

Check your hearing: Adjustment period for hearing aids 2-4 weeks

4. Make your home safer4. Make your home safer

Most people fall at home8

55% inside house

23% outside, but near house

22% away from home

4. Make your home safer4. Make your home safer

4. Make your home safer4. Make your home saferNegative stigma of home safetyAssociated with “old age”

Visibility (grab bars, ramps)

People will accept some modification recommendations, but not all

Old habits are hard to change

4. Make your home safer4. Make your home saferNo cost home modifications• Clutter removal form stairs & walkway

• Rearranging furniture and cords

• Cleaning walkways

• Remove throw rugs (or use double sided tape)

• Place items on lower shelf

• Put phone within reach of floor

4. Make your home safer4. Make your home saferLow cost home modifications: • Replace burned out light bulbs• Install night lights• Non-slip rubber bathmats or self stick

strips• Replace home footwear (non-slip, non-

stick)• Elevated toilet seat• Carpet firmly attached to every step• Fire alarms. Emergency response

systems

4. Make your home safer4. Make your home saferAssistance with modifications:

• Rail installation both sides of indoor / outdoor stairways

• Grab bars around toilet and in tub / shower

• Ramps if stairs are a problem• New lighting fixtures• Lights at top & bottom of stairs w/

switches• *Boeing Blue Bills—assistance w/

installation

4. Make your home safer4. Make your home safer

Other modifications:

Fix loose handrails

Place lamp next to bed and within reach

Nightlight from bed to bathroom

4. Make your home safer4. Make your home saferOther safety recommendations• Use brighter light bulbs• Paint contrasting color on top edge

of steps• Keep emergency #’s in large print

near phone• Put phone on floor in case you fall• Talk to your neighbor• Clean up spills immediately• Never brace on towel bar

4. Make your home safer4. Make your home saferOther safety recommendationsRun electric cord against walls,

never under rugs or across doorways

Do not step over sleeping pets

Water heater below 120 dg F (burns can startle and cause falls)

Get up slowly after you sit or lie down

4. Make your home safer4. Make your home safer

What you can do to What you can do to prevent fallsprevent falls

1)Begin a regular exercise program

2)Have your doctor review your medicines

3)Have your vision checked

4)Make your home safer

Special Thanks to: Wellness Committee

ResourcesResourcesActive Life Physical Therapy Port Ludlow:

www.activelifetherapy.comHome Instead Senior Care

www.homeinstead.com/650/Pages/HomeInsteadSeniorCare.aspx

Olympic Area Agency on Aging: www.o3a.org/ECHHO: http://echhojc.org/Boeing Bluebills Olympic Peninsula:

www.bluebills.org/olympic.htmlCenters for Disease Control and

Prevention www.cdc.gov/National Osteoporosis Foundation » http://www.nof.org/American Physical Therapy Association: www.apta.orgWA State Dept. Of Health www.doh.wa.gov/ Washington State Falls Prevention web site

www.fallsfreewashington.org

ReferencesReferences 1. American Geriatric Society, British Geriatric Society, American Academy of

Orthopedic Surgeons Panel on Falls Prevention. Guidelines for the Prevention of Falls in Older Persons. JAGS 49: 664-672, 2001.

2. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web–based Injury Statistics Query and Reporting System (WISQARS) [online].   Accessed November 30, 2010.

  3. Duncan P, Studenski S, Chandler J, Prescott B. Functional Reach: a new clinical

measure of balance. J Gerontol 1990; 45M192-M197.   4. Englander F, Hodson TJ, Terregrossa RA. Economic dimensions of slip and fall

injuries. Journal of Forensic Science 1996;41(5):733–46.trial. The Gerontologist 1994;34(1):16–23.

  5. Hausdorff JM, Rios DA, Edelber HK. Gait variability and fall risk in community–

living older adults: a 1–year prospective study. Archives of Physical Medicine and Rehabilitation 2001;82(8):1050–6.

6. Hornbrook MC, Stevens VJ, Wingfield DJ, Hollis JF, Greenlick MR, Ory MG. Preventing falls among community–dwelling older persons: results from a randomized trial. The Gerontologist 1994:34(1):16–23

7. Issue Brief (Public Policy Inst (Am Assoc Retired Pers) 2002 Mar;(IB56):1-14.

8. Kochera A. Public Policy Institute, American Association of Retired Persons, Washington, DC, USA. Falls among older persons and the role of the home: an analysis of cost, incidence, and potential savings from home modification. 2002.

References References 9. Morrison, C. Northwest Orthopaedic Institute. Proven Best Practices:

Assessment and Treatment of Patients Who are at Risk for Falls. Gentiva Seminar. Attended October 20, 2006.

  10. National Hospital Discharge Survey (NHDS), National Center for Health

Statistics. Available at: www.cdc.gov/nchs/hdi.htm.  Assessed September 14, 2011.

  11. National Fire Safety Council, Inc., Michiagan Center, MI 49254-0378. Falls

Prevention: Protecting Your Active Lifestyle.

12. Podsiadlo D, Richardson S. The timed “Up and Go” test: a test of basic functional mobility for frail elderly persons. J Am Geriatr Soc 1991; 39:142-148.

13. Roudsari BS, Ebel BE, Corso PS, Molinari, NM, Koepsell TD. The acute medical care costs of fall-related injuries among the U.S. older adults. Injury, Int J Care Injured 2005;36:1316-22.

 14. Shumway-Cook A, Woollacott M. Motor Control Theory and Practical Applications, 2nd Ed. Lippincott Williams & Wilkins. Baltimore, MD 2001.

15. Tinetti ME. Clinical Practice. Prevention Falls in Elderly Persons. N Eng J Med 2003; 348:42-49

ReferencesReferences 16. Washington State Department of Health: Senior Falls Prevention

Study 2006

  17. York, S. Northwest Orthopaedic Institute. Proven Best Practices:

Assessment and Treatment of Patients Who are at Risk for Falls. Gentiva Seminar. Attended October 20, 2006.