What is a fall?
There are many definitions for falls. Within most definitions will be an idea that a falling is considered unintentional, to a lower level than before such as the floor or the ground, and it is neither explained either by medical causes such as blood pressure or a stroke nor caused by an overwhelming external force. A simple and widely accepted version often used in used in research defines a fall as:
“An unexpected event in which the participant comes to rest on the ground, floor or lower level” (Lamb et al 2005).
Falls and poor bone health are a major cause of disability and accidental home deaths in the older population. Research into causative factors and prevention of falls show that many of the interventions provided through physiotherapy, or physiotherapy as part of a team can be provided in different settings, and can modify the risk and help to prevent future falls.
There is a notable trend of increasing falls in the older population, and these have been recorded as being common causes for admission into hospitals. An example in the UK can be illustrated by the Hospital Episode Statistics [HES] data below
Just 'being old' however, is not an acceptable justification for a fall, and not all falls can be explained. Clinically, the therapist may come across the phrase ‘mechanical falls’; a misleading term which may result in no further investigations being undertaken when in fact there is a need for ongoing management e.g. strength and balance work. It is better to regard falls as either explained or unexplained. For example, an unexplained fall found on investigation to be due to due to overmedication resulting in a postural drop and collapse as compared to a trip over the carpet edge.
An assessment of bone health alongside a falls assessment can ensure older patients who may have osteoporosis can be identified and receive appropriate treatment to reduce their risk of osteoporosis or fragility fracture following a fall. Likewise there should be access to a falls assessment within bone health services (NICE 2004) as there is a huge impact on the cost of managing falls related fractures.
Causes of falls:
Ageing, pathology, inactivity and environmental factors all increase the risk of falls and fall related injuries. Falls have a multi-factorial aetiology, with over 200 risk factors identified (Lord et al 2007). As it would not be feasible to identify all risks, NICE (2004) recommend identification and assessment of the leading causes of falls.
Leading causes of falls
Information relating to falls history i.e. previous falls
- Alteration to gait, balance and mobility, or muscle weakness
- Older person’s perception of functional ability and fear relating to falling
- Visual impairment
- Cognitive impairment and alterations on a neurological examination
- Urinary incontinence
- Presence of home hazards
- Cardiovascular pathology
- Medications prescribed
The Postural Stability Instructor Course for Laterlife Training (see resource in Further Reading section below) categorises the majority of contributing factors to falls using the acronym DAME
- Drugs and alcohol: The response to certain drugs, including alcohol alters with age. See section on Medication issues as polypharmacy is an independent factor for falls.
- Age related physiological changes: A decline in physiological and psychological systems eventually impact on balance, range and speed of movement. This poverty of (re)action puts the body at risk of falling. This includes age related changes in each of the sensory systems as well as in the cardio-respiratory or neurological systems each affecting the body's response to threats
- Medical – includes psychological as well as biological factors: The ageing process leaves the body open to developing a variety of commonly seen conditions with both mental and physical health attributable. An anxiety state or depression may hinder and limit a patient’s participation and progression with physiotherapy, plus there are some commonly recognised psychiatric conditions that put a person at risk of falls or poor bone health through inactivity.
- Environment: Many older people fall (trip or slip) inside the home or home surroundings. The interaction between physical ability and environmental factors cause falls, and taking risks or being impulsive will further increase that risk (Lord et al 2007). Household hazards such as loose rugs, low furniture, clutter, pets and the stairs pose the greatest risk. Reducing hazards is ineffective unless provided with training to improve transfers and strategies to assist in changes of behaviour. Outdoor hazards include poorly lit areas, uneven ground and wet / icy conditions (Lord et al 2007). Inappropriate clothing (too long or restrictive) and ill-fitting shoes or slippers are also factors that affect balance and safe mobility.
Falls risk factors have been further categorised into intrinsic and extrinsic. Intrinsic risk factors are traits of an individual that increase their risk of falling (Smith 2004); these are more important amongst the oldest age group and can be related to neurosensory impairment, certain drugs, or the presence of diseases associated with an increased risk of falling (e.g. Parkinson's disease, stroke, osteoarthritis or diabetes). The risk of having a fall or recurrent falls increases with the number of associated intrinsic risk factors.
Extrinsic causes are social and physical factors that relate to an external environment, unrelated to disease or drug use; a slip on ice for example. Falls amongst people < 75 years are more likely to be due to extrinsic factors than those aged 75 and over. If both intrinsic and extrinsic factors are present, falls are classified as combined (Formiga et al 2007, Lord et al 2007)
Management of falls
The physiotherapist’s skill is to work with the interdisciplinary team (whether actual or virtual) and investigate possible falls causes, working holistically to address issues (Squires and Hastings 2000). Management is multifactorial aiming to prevent and minimise future falls risks. Most falls are caused by slipping, tripping, or stumbling, not by dizziness or disorientation (Lord et al 2007). They can occur during walking or standing if the person cannot recover quickly or effectively enough to stop the fall. The ‘margin for error’ when moving and standing decreases as reflexes slow and strength decreases as can happen if an older person becomes more sedentary or affected by disability, so a weakening of the balance system can no longer be compensated. Lord et al (2007) consider that starting to fall is normal thus every step taken is a type of controlled fall. The issue is to establish how a person might stop the fall becoming uncontrolled.
A fall or potential fall event should be assessed through multi-factorial tools such as the Physiological Profile Assessment (PPA). This screening procedure evaluates an older person’s likelihood of falling (Lord et al 2007). It involves a comprehensive series of simple tests of vision, peripheral sensation, muscle force, reaction time, and postural sway that can be administered quickly with portable equipment. The results can differentiate people at risk of falls (“fallers”) from people less at risk (“nonfallers”) as the tests identify specific contributions of the visual, vestibular, proprioceptive, and musculo-skeletal systems to create a ‘balance profile’. The research shows the difference between instability produced by failing strength, decreased leg sensitivity (e.g. from diabetes), visual problems (e.g. glaucoma), and other issues.
Physiotherapy assessment and intervention
The physiotherapist should be clear why they are asking specific questions and what they need to physically assess to guide their management options. A good history allows the clinician to build a picture around the falls and identify any patterns, risk factors or causes, leading to a possible explanation or clinical diagnosis. Other professionals (whether qualified and unqualified, of a health or social care background) may have completed a falls ‘screen’ rather than a full multi-factorial falls risk assessment. Apart from the financial costs to the health system falling can have a major impact on a person's lifestyle as well as that of their family (Lord et al 2007). Psychological and physical consequences of falling include loss of confidence, activity restriction, social interaction and an increased dependency on carers that can cause family or carer strain (Elliott and Pezent 2008, Martin et al 2008, Lord et al 2007). A scale such as the Falls Efficacy Scale International (FES-I) developed through ProFaNE (See Further Reading section below) might be used to determine a patient’s confidence when performing activities. It can highlight when the fear of falling may be preventing activity and therefore needs addressing.
A thorough physiotherapy assessment might identify additional cause(s) of falls not previously known that might be addressed. To include falls and near misses (also indicators of falls risk), it is recommended to pose the question using the following wording:
“In the past month, have you had any fall, including a slip or trip in which you lost your balance and landed on the floor or ground or lower level?” (Lamb et al 2005)
Your physical examination should include assessment of gait, balance, joint range of movement and muscle strength. It is recommended that validated assessment tools are used. Ones such as 'Timed get up and go’ test, Berg balance test' etc can be found via a good health library database. Functional ability can be reviewed through subjective questioning e.g. how a person manages personal and domestic activities of daily living; or observation of how the person stands up from a chair etc or can multi-task e.g. walk and carry objects. Poor response in a dual-task setting is a possible prognostic value for multiple falls (Faulkener et al 2007).
In addition to treatment of specific injuries that might have been sustained during a fall four main physiotherapy goals have been identified when working with older fallers (AGILE 1998).
Physiotherapy goals with fallers
- Prevention of further falls – by working on mobility, balance, and strength
- Training clients to cope with further falls and minimise the consequences of a long lie; teaching them ways to get off the floor or means to call for help, and in the meantime how to keep warm
- Ensuring their living environment is as safe as possible
- Restoration of confidence and self-esteem to improve their quality of life
The correct treatment strategy is based on evidence of falls factors physiotherapy intervention can improve / alter. These include complex mobility e.g. as post-stroke, Parkinson's Disease with freezing; co-ordination and balance; flexibility; strength and endurance; fear of falling; confidence; getting up from floor (Backward chaining is the method of preference as it provides a useful step by step method of getting down onto, and then getting back up off the floor. The individual is not allowed to progress to the next step of the chain before they have mastered the one they are on, and it may take several goes before someone frail can get onto / off the floor).
For physiotherapists, exercise (for strength and balance) has been shown to have the most effective outcomes in reduction of falls rates (Sherrington et al 2008). As the majority of people who attend such programmes relapse into old ways by six months, the physiotherapist should attempt to reinforce and encourage good behaviour, eliciting ideas of what might keep the person motivated both during the course of the programme and into the future.
Sherrington et al’s research (2008) demonstrated that clinicians have to ensure that:
- The balance training is highly challenging, should be individualised & progressive
- Exercise should be at least twice a week and for a minimum duration of 6 months
- Walking should only be prescribed in addition to a high intensity / high dose programme
Sherrington et al (2008) also found that people in sub-acute hospital inpatients settings could also benefit from a multi-factorial intervention – particularly those at high risk of falls if the fall was related to postural instability. The person had to be able to participate in a 45 minutes group exercise session at least 3 x week for the duration of their stay.
It is becoming increasingly recognised that Falls Prevention requires a change in the person’s behaviour and should be approached from a psychological, and not just a physical perspective; this is becoming the focus of health promotion and it is such multidisciplinary intervention that has been proven to be of most effect for fallers (NICE 2004). Games such as those available through the Nintendo Wii system allow people to practice at home and to monitor their goals following gains they made from a Falls programmes. They were designed to, and are proving a fun way to engage people in intergenerational physical activity, and many rehabilitation units are using these systems to improve physical function. Also, now the links between exercise referral schemes are increasing, more people are continuing activity in places such as gyms, that they may never before have had a chance to access.
Physiotherapists are key in helping people to achieve maintain fitness levels and thus minimising falls risks
AGS/BGS Clinical Practice Guideline: Prevention of Falls in Older Persons. Accessed at: http://www.medcats.com/FALLS/frameset.htm [accessed online 28.4.11]
Lord S, Sherrington C, Menz H, Close J (2007). Falls in older people – Risk Factors and strategies for prevention 2007 (2nd edition) Cambridge University Press
Department of Health UK (2009) - Prevention Package for Older People. Accessed at: http://www.dh.gov.uk/en/SocialCare/Deliveringadultsocialcare/Olderpeople/Preventionpackage/index.htm [accessed on line 01.09.2009]
The ProFaNE network (of 25 partners) focus on the issue of prevention of falls and improvement of postural stability amongst elderly people across Europe (http://www.profane.eu.org/about/about.php?sid=fc1d3cc0a77a46d58df3db12002d37af) and the Falls and Balance Research Group based in New South Wales, Australia are leading the field of applied research examining different factors that contribute to older people falling and experimental interventions to decrease the contribution of any single factor.
The Postural Stability Instructor Course for Laterlife Training: http://www.laterlifetraining.co.uk/page5.html
Falls factors (from the UK Department of Work and Pensions site) - Do we need Janet?
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