Among the myriad challenges faced by PTs every day, fall prevention is growing in importance. With an aging population, and a dangerous potential for severe health risks from falls in older adults, PTs are increasingly called upon to help patients regain their balance and quality of life.

But with traditional PT techniques and tools, the ability to effectively prevent falls is limited. As the issue grows in prominence and fallout, new products and technologies are emerging to fill these holes. To understand the importance of these new tools, and the considerable potential they represent, we must first acknowledge the problem falls present, as well as the challenges faced by PTs in preventing them.

THE FALL EPIDEMIC

Falls are a significant and growing problem, as PTs know well. Falls and fall injuries are more common than strokes and can be just as serious in their consequences. They also are the most preventable cause of needing nursing home placement. According to the Connecticut Collaboration for Fall Prevention, based at Yale University School of Medicine, among adults 70 years and older:

• 3 in 10 fall each year;
• 2 in 10 who need home health care after being in the hospital will fall during the first month after coming home;
• 1 in 10 suffer a serious fall injury such as a broken bone or head injury; and
• 5 in 10 have problems getting up without help after they have fallen.

Risk factors for falls run the gamut of bodily and environmental issues. Environmental hazards are the leading cause of falls, accounting for 25% to 45% in most studies. Unsafe footwear, the use of assistive devices, items in the home that can be easily tripped over, and more are the root of these issues. Falls also can occur with patients who have problems walking or moving around, visual disturbances, blood pressure issues, dizziness and vertigo, and muscle weakness.

Additionally, those older than 80 years are much more likely to fall, as well as those with arthritis and depression. Use of certain medications also has been strongly associated with an increased risk of falls. In particular, use of psychotropic medications, cardiac drugs (including class 1A antiarrhythmic agents), digoxin, diuretics, and anticonvulsants have been implicated in increasing the risk of falls. Patients who rely on a mix of medications, particularly those who take four or more, increase their risk of falling.

Of course, patients who have previously had a fall will more likely have another. In many cases, these patients will avoid putting themselves in situations where falls might occur out of self-preservation. While this may be a sound idea, it also leads to a disuse of their balance reaction, increased anxiety, and can even lead to depression and social isolation. It keeps these patients in a perpetual waiting pattern, one that significantly reduces their quality of life and ability to physically prevent falls.

To tackle the problem of falls, and to think realistically about preventive methods that can be incorporated into physical therapy, numerous studies have examined intervention methods. In a 2002 study that appeared in American Family Physician, more than 1,000 independent seniors were divided into treatment groups. No intervention resulted in 63.5% of seniors having at least one fall. Exercise reduced that percentage to 56.3%; home hazard management reduced the number of falls to 57.4%. The best intervention method involved a multifaceted campaign of exercise, vision acuity work, and home hazard management, which resulted in only 48.1% of seniors having at least one fall.¹

The takeaway from this study and multiple others over the past decade has been the need for a comprehensive, multifactor approach to fall prevention. To effectively manage the issues and the interventions for fall prevention, physicians and patients are increasingly turning to PTs.

THE PT APPROACH

PTs can be challenged by both assessment and treatment of balance dysfunction, in what is characteristically an elderly patient population. Assessment for fall risk should include a full description of functional mobility, acute and chronic medical history, medication use, and cognitive status. If falls have already occurred, the evaluation will also cover the circumstances surrounding the falls.

"Some of our geriatric patients can be unreliable historians," says Sadie Woods, PT, manager of rehab services at the Alice Peck Day Memorial Hospital, Lebanon, NH. "The challenge is to try to glean from whatever medical records are available as comprehensive a picture as possible. The reason a fall occurs can be complicated. I try to get a sense of all the issues—talk to the PCP, study past history, and talk to the patient and spouse or caregiver."

With thorough assessment and evaluation, PTs then have a number of interventions at their disposal. The need for a multifaceted treatment plan is a given, so interventions may incorporate gait and balance training, review and modification of medications, removal or adjustment of environmental hazards, therapeutic exercise, and other condition-specific treatments.

For Woods, clinically based treatment is threefold. If the physical culprit is a vestibular issue, the goal is to reposition calcium carbonate particles in the semicircular canals, where they disrupt signals to the brain and trigger vertigo. To do this, she incorporates Epley's maneuver, using vibration against the mastoid.

If the issue is a lack of flexibility and strength in the core and lower extremities, Woods may incorporate stationary biking and lower-extremity strengthening and stretching exercises. To improve proprioception and kinesthetic sense, she also will use traditional equipment like Dynadiscs and tilt boards.

The final piece in Woods' approach to treating fall reduction is a new tool offering patients the ability to practice balance reactions in a safe environment. With the Simbex ActiveStep, Woods has filled a hole that existed in previous treatment plans that gives patients their function and confidence back.

ACTIVESTEP

Simbex, based in Lebanon, NH, developed ActiveStep™ as a system that measures the efficiency of an individual's recovery response to a fall. The device then retrains the response to bring it back to a more effective level. The tool is based on research originating from the University of Illinois at Chicago, in which investigators identified two major aspects of balance reactions that prevent falls. Some individuals can reassert control through their trunks, using their back or abdominal strength to pull their trunk back over their feet upon beginning to fall. Other individuals correct themselves with a recovery step, using a fast enough and long enough step to halt the forward momentum upon tripping. ActiveStep bases its treatment methodology upon measuring these two aspects for a patient and developing an individual means for practicing better responses.

The user walks on a treadmill, protected by a suspension vest that holds them upright upon any loss of balance. Using a simulator training approach, the machine creates postural disturbances programmed into the treadmill. At each imbalance, the body reacts with compensating movements and practices recovery from potential falls. Over a session, and with repeated sessions, the device helps train patients on their automatic reactions, improving upon recovery step (step-length, step-width and timing, toe-off, heel strike) and the position and velocity of trunk-recovery movements to create responses better able to prevent falls.

The fall-prevention training often can result in improvement over a single session, and increased ability to maintain balance after multiple sessions. The training and the programmed perturbations are geared specifically to each patient and their strengths and weaknesses to produce a comfortable, safe, and reassuring environment.

Woods uses the ActiveStep frequently in her practice, and sees an average improvement in the "Timed Up and Go," or TUG, test of 28% after use. One particular case study demonstrates the device's ability to reduce the potential for falls and resulting injury, as well as the ability to overcome the patient's resistance to the idea.

"One of the things we can be up against with elderly patients is that generation's perception of 'exercise' as frivolous," Woods says. "They grew up in a different time and can view physical therapy as unnecessary and the ActiveStep as a gadget or gimmick. One of my patients was a quite skeptical 92-year-old dairy farmer whose wife persuaded him to come for physical therapy. However, after only two or three sessions, he improved his TUG score by 5 seconds, which is fairly impressive. Once I pointed this out to him, he realized his time was well spent and completed eight sessions."

One of the biggest benefits of ActiveStep is the increased options it gives to PTs.

"I knew what I wanted and needed to do with these patients," Woods says. "I wanted to be able to simulate perturbations of static and dynamic balance, and enable patients to practice their response while ensuring their safety. I could have them stand on one leg, walk on a balance beam, and complete other balance tasks. That has some merit, but ActiveStep more realistically simulates what they're experiencing in their home and community and allows them a safe way to practice balance reactions. It effectively fills that hole and is an important addition to what is a multifaceted treatment plan for reducing falls and improving mobility for people at risk."

NEW TOOLS

The advent of the ActiveStep tool represents a major step forward for PTs working to prevent falls. But it also represents something else. The big news today in the medical world and throughout society is the aging of the Baby Boomer generation. As this mammoth section of the population grows older, fall prevention becomes even more of a pressing issue. From a public health standpoint, and from a cost-containment perspective, preventing the dangers of falls is increasingly important.

To that end, the market has responded. ActiveStep is one entry in a growing field of assessment and training methods for balance and general fall prevention.

The Balance System SD™ is another. It was designed to improve balance, increase agility, develop muscle tone, and treat injuries and chronic conditions. Developed by Biodex Medical Systems, based in Shirley, NY, the tool is also useful in fall prevention, providing screening and conditioning for falls.

The tool has patients step up on a platform facing a monitor. Therapists can program test protocols into the machine, including fall risk, single-leg stability, limits of stability, and postural stability. The touch screen guides patients through testing and training modes, including exercises in balance training, proprioception, range of motion, and weight shift. Overall, therapists can assess neuromuscular control on a static or unstable surface, and train to enhance kinesthetic abilities.

From Metitur USA, based in Colleyville, Tex, comes the Good Balance system. A balance measurement and training system, the Good Balance is a moving three-angular force platform offered in different sizes. Utilizing Bluetooth data-transmission technology, the system measures postural control in different conditions (static and dynamic), and then offers training methods through visual and auditory feedback. This biofeedback method of balance training is billed as motivating and easy to use, where patients can monitor their own progress and train their functional dynamic movements.

The BalanceQuest, from Micromedical Technologies in Chatham, Ill, offers a "floating" platform that mimics natural conditions disturbing proprioception. As an assessment tool, the Balance Quest allows therapists to determine balance issues as due to misinformation or misinterpretation of sensory and motor inputs.

Patients stand on a platform, protected by guardrails. When activated, the platform floats on a spring suspension with 6° of movement. Using several visual stimulus options, the therapist can identify the root of the problem. The virtual environment glasses and optokinetic ball, for example, simulate interference with visual cues for assessment. During rehabilitation, the tools can gradually retrain patients to compensate for any deficits.

Finally, the Balance Master presents another option for inclusion in a fully multifaceted approach to fall prevention. Developed by NeuroCom International, Clackamas, Ore, the Balance Master comes in several models offering comprehensive assessment and rehabilitation options. The Smart Balance Master, for example, has patients step onto a platform surrounded by a screen and progress through balance tests. Throughout the models, the goal is objective assessment and retraining of the sensory and voluntary motor control of balance.

Preventing falls is an important endeavor. With comprehensive physical therapy programs that incorporate tools like those described in this article, PTs now have an even more powerful means to restore this quality of life to their patients.

Amy Lillard is a contributing writer for Physical Therapy Products. For more information, contact .

REFERENCE

1. Walling AD. Preventing falls: which intervention is most effective? Am Fam Physician. 2002;66(10):1943–1996.