Falls and Traumatic Brain Injury

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Introduction

We are witnessing the populations across the world aging dynamically. The Great Britain older people population is increasing (according to ONS in 2018 one in 5 was 65 or over when by 2050 one in four people will be 65 or over). Due to the advances in emergency medicine, intensive car and neurorehabilitation we are also witnessing the increase in the population of people leaving with acquired brain injury. 

Falls tie age with traumatic brain injury in a two-way relationship. 

1. Falls are the leading cause of the TBI including children and older adults population with the greatest incidence in 83-90 years old. Falls are also the second leading cause of death related to accidental or unintentional injury worldwide. One out of five falls causes a serious injury such as broken bones or a head injury, which approximately three quarters requires hospital admission. The cost of falls for the British NHS is approximately £4.6 millions a day! Mortality in older adults following TBI is significantly increased. Older adults represent approximately 10% of all the population of patients with TBI, however they represent 50% of TBI-related deaths (Eapen at al 2018). The chart reflects the TBI causes in USA, but the trend of falls being most common TBI cause is now global. https://www.brainline.org/slideshow/infographic-leading-causes-traumatic-brain-injury
2. Traumatic Brain Injury causes often complex multisystem impairment and requires multifaceted therapeutic intervention. Moreover, the Rehabilitation itself exposes TBI survivors to greater risk of falls. Therefore, the risk and occurrence of falls in this population and settings is much greater and majority of individuals with TBI will be at risk of falls.

A Fall is as an event which results in a person coming to rest inadvertently on the ground or floor or other lower level. Fall-related injuries are mostly non-fatal but can also be fatal (WHO)

Risks of Falls and Contributing Factors

• Age (the most susceptible groups are people at the age of 65 and older with the higher risk of serious injury like head trauma, and children under 15 when combined with insufficient supervision from adult. Older adults who hit their head due to fall are more likely to have brain injury due to age related changes in brain structure and circulation as well as medication taken like blood thinners.)
• History of Fall (Half of people who fall will fall again in the next 12 months)
• Fear of falling (might relate to being cognitively preoccupied when being anxious and impacting attention and use of cognitive reserve which would mimic dual tasking conditions. Fear of falling causes reducing activity level)
• Decreased muscle strength, altered muscle tone, flexibility or insufficient balance system (Impaired balance results in gradual withdrawal behaviour from more complex activities like community mobility or playing sports, and adjusting execution of some tasks like using trolleys to carry drink, etc)
• Polypharmacy (4 or more prescribed medication significantly increases the risk of falls)
• Visual deficits or visuo-spatial disturbances
• Vestibular Disorder like BBPV, labyrinthine concussion, etc
• Cognitive deficits which could manifest as slow processing, impaired executive functions, attention deficits, inability to dual task/multitask (2 in 3 people with dementia or cognitive impairment will fall next year)
• Low mood and related medication
• Incontinence
• Chronic Condition, i.e.: TBI, Stroke, MS, MSK Diseases, dementia
• Short term factors like medication side effects, alcohol intake
• Activity related like walking, stairs climbing, 
• Environmental factors like light poor lighting, bad kitchen organisation, carpets and rugs, clothing and footwear

This means that physical and cognitive falls risk factors overlap strongly with TBI sequels and point to TBI survivors as at greater risk than general population. The risk is not clearly age related and people with TBI are at risk of falls at any age. People with TBI report disequilibrium in sitting or standing or various forms of dizziness (approx. 30-65% of TBI survivors) affecting activities of daily living and mobility. The severity of the problems depends on severity of the injury, location of injury, other injuries accompanying TBI or other comorbidities and medication related to TBI. It needs to be noted that Rehabilitation itself imposed increased falls risks and there is a trend of falls in neurorehabilitation settings during active times (McKechnie at al 2015). Physiotherapist should regularly reassess the risk of falls in patients with TBI as the change in them is not linear with the recovery time either general outcomes.

Prevention and Treatment

The preventative activities should be multifactorial and aim to reduce number of falls or severity of falls related injuries should they occur. According to the World Health Organisation the elements to include in programmes preventing falls are:

1. Motor-cognitive falls interventions for people with falls risks, fear of falling or history of fall/s
2. Education strategies rising awareness about falls risk and prevention
3. Creating safer environments
4. Training health care professionals about falls risk, burden and prevention.

Multifactorial interventions with emphasis on behavioural change impacting the lifestyle choices and addressing environmental factors are deemed to have the highest effectiveness (Sherrington, Shumway-Cook). There is a strong belief those interventions should be long term and contain at least 50 hours of exercises over 6 months.

Multiple and complex TBI sequel are often overlapping with impairment contributing to falls risk like weakness, reduced joints mobility, stiffness, slow processing speed, inability to complete complex tasks. In case of ongoing existence of impairment affecting balance and postural control reflected in balance and mobility outcome measures like BBS or TUG people with TBI should continue working on prevention of falls and have access to professional advice and interventions upon discharge from Neurorehabilitation Services. (Klima at al 2018)

The multifactorial preventative and reactive approaches should:

• Encourage patients to share information about their falls with General Practitioners or Physiotherapist. Professionals to obtain and store the data to establish patients at risk
• Contain education about fear of falling impact on daily activity level and participation as well as developing coping strategies like building confidence through practice of on/off the floor transfers [send you a document separately you can upload to your resources and cross reference], rolling and crawling on the floor, exposing to near falls with developing the sensory memory about initial stages of falls and learning how to react to avoid fall
• Build progressive, optimally challenging exercise-based programmes addressing strength, flexibility, agility and balance systems training
• Contain vestibular, visual, proprioceptive demand during exercise training using scanning, head movements, eyes closed/open, even/uneven base of support, etc.
• Include dual tasking demands using additional motor or/and cognitive tasks, increasing complexity and speed of practice
• Including cognitive-motor tasks enhancing thinking related to mobility and balance using tools like dance mat, “Clock yourself app” 
• Contain medication review every 12 months against accumulative side effects and further need of use of particular medication
• Include regular vision assessment and promotion of habits like cleaning glasses daily
• Contain vestibular assessment and treatment when required
• Include psychological and emotional wellbeing review and treatment based not only on pharmacological agents
• Include regular continence review when required
• Include environment and personal choices review and advice about lighting, kitchen or bathroom organisation, decluttering, marking stairs, avoiding carpets or rugs, choosing stable supportive footwear, comfortable but neat clothing of right length, animal keeping, etc.

Various balance components should be integrated into balance retraining exercise programmes:

• Postural alignment, body mechanics, and static postural control including midline orientation (steady stance)
• Dynamic postural control, including musculoskeletal responses necessary for control of movement and posture including strength, flexibility and ability to make effective anticipatory postural adjustment prior to voluntary movements (pro-active and reactive balance components to address various tasks’ attributes requiring stability, mobility or skills)
• Balance skills and balance reactions repertoire for various task and environmental conditions like ankle, hip, stepping strategies
• Mobility training
• Use of sensory monitoring for postural control (visual, vestibular, proprioceptive)
• Cognitive skills training with evidence emerging that cognitive-motor tasks combined have the greatest effectiveness (Sturnieks at al 2019)

The training to be efficient needs to meet individual person’s needs and be designed at optimal level of challenge balance components without compromising safety. Working in a comfort zone, i.e.: using chair-based exercises programme only is not going to address balance either reduce the falls risk. Equally, working only on one balance components, i.e.: strength is not going to address the complexity of balance. 

Use of various postural sets and techniques like rhythmic stabilisation or stabilising reversal, even versus uneven base of support like balance pads, reduced base of support like feet together, tandem standing/walking, 1 legged standing, use of head and upper limbs movements, complexity of tasks like dual tasking with cognitive or additional physical element can be used to tailor the programme to individual’s goal. 

There are well research programmes for falls prevention and mobility and balance retraining, which were designed for other patients population like stroke survivors or elderly, however their principles and routine can be apply successfully in falls prevention after TBI:

1. Otago Exercise Programme Manual could be found here or apps used electronically
2. FAME developed at University of British Columbia by Prof Janice Eng’s Team with easy accessible resources which can be used on electronic devices or printed 
3. Falls Management Exercise (FaME) developed by Later Life Training and Prof Dawn Skelton in UK with implementation toolkit downloadable here

References