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Neurologic/Geriatric>>Balance & Falls - 1/5/2007

Balance & Falls

By Kevin Lockette PT


Introduction/Epidemiology:  Falls and the consequences of falls such as hip fractures, can be devastating to both older adults and their families.  Often times the consequences of falls no longer allow older adults to live independently at home.  Among older adults, injuries are the sixth leading  cause of death in people over 65 years of age, and cause more deaths than either pneumonia or diabetes.  In the United States, approximately 10,000 deaths each year are related to falls- the majority of these are related to hip fractures.  Falls are the leading cause of unintentional injury at home among Americans 65 and older per  the  “Special Report: Emergency Room Injuries Adults 65 and Older”.  Despite the statistics, many times falls can be prevented by understanding the different balance factors and by either changing or compensating  for both the intrinsic and extrinstic factors that lead to falls.  


Intrinsic factors/risk for falling:  Balance factors can be broken down into 2 categories.  The first being intrinsic factors which related to a person’s physical capabilities and characteristics and the second being extrinsic factors which relate to one’s environment or anything outside of the physical body itself.  The three physical balance systems are vision, somatosensory/proprioception, and vestibular system.


     Vision:  Age-related changes in vision can decrease the ability to accurately perceive changes in surface conditions or the presence of hazards in the environment. The increasing prevalence of eye diseases such as cataracts, glaucoma, and macular degeneration among older adults has also been associated with increasing fall rates.  Regular eye exams and check-ups can decrease risk for falls by minimizing visual deficits allowing for better anticipation changes in surfaces and in perceiving environmental hazards such as negotiating curbs, stairs and uneven terrain. 

     Somatosensory/proprioception:  The somatosensory system provides the information about the spatial relationship of the body to the support surface.  It is basically the ability to feel the surface your are on wether it be the firm surface of wood floors or the soft surface of a padded carpet.  In the absence or decline in vision, the somatosensory system becomes the primary source of sensory information that is provided for balance as well as moving around in dark areas.


     Vestibular system:  The final balance system is the vestibular system.  This is the system that is housed in the inner ear and is activated when one moves his head. The vestibular system becomes very important when the other two systems are impaired.  Examples are when one is walking on uneven terrain which disrupts the somatosensory system or the ability to feel in conjunction with really crowded areas or darker areas that can distort vision.  The vestibular system is trainable and can be taught to better compensate for visual and/or sensory deficits. 


Other intrinsic factors include posture changes and neurological insults such as strokes and Parkinson’s disease. 


     Posture/osteoporosis:  Good posture is critical to good balance and refers to the body’s alignment.  With age, some people can develop  a kyphotic posture which is a hump in the upper back.  This posture causes a forward head and a hyperextension of the neck to be able to scan the environment in front versus looking at the ground.  This postural change moves the center of gravity making one more susceptible for falling posteriorly, especially with walking up inclines.  Poor posture can also lead to compression fractures.  


     Chronic illnesses:  Suffering from a stroke or other diseases such as Parkinson’s disease, osteoarthritis, and other neuromuscular diseases can greatly increase the risk for falls.  Much of the increase risk involves the paralysis of muscle groups, weakness, pain, and changes in muscle tone.  Knowledge of the nature of one’s deficits can assist greatly decreasing fall risks. 


Even though one may not have control over certain intrinsic factors such as macular degeneration or hemiparesis following a stroke, risks for falls can greatly be decreased by knowledge of one’s physical limitations and at risk situations as well as training the body to compensate for impairments in one or more of the balance systems.  Physical therapists can aid greatly identifying fall risks and with teaching and training of exercises and activities.


Extrinsic factors/risk for falling

In addition to the intrinsic factors, extrinsic factors can affect ones risk for falls.  The two primary external risk factors are medications and the physical environment.


     Medications:  Older adults who are taking  four or more prescription medications are at higher risk for falls.  Certain medications have side effects that can contribute to fall risk as well as the interactions of some drugs and supplements can cause adverse affects leading to falls.  Certain classes of prescription medication are associated with higher fall risk than others.  These include sedatives/hypnotics, antidepressants, and psychotropic medications.   It is highly recommended that you keep a consolidated drug list that you can take when you see your primary care physician or any specialist so that they are aware of what you are taking and do not prescribe a medication that does not interact adversely with a medication or supplement that one is already taking.   If you are uncertain, it is best to put all of the supplements and prescription medications in a bag and take it to the primary care physician or pharmacist. 


      Environment:  The second external factor that can have direct impact on one’s fall risk is the physical environment itself.  Many hazards can be at your home including floor rugs that are not secured down, exposed electrical or appliance cords, poor lighting, need for grab bars in the restroom, clutter,too soft plush carpet, absence of night lights, cabinets too high, furniture too low, thresholds into different rooms, etc. 


Below are some simple home safety strategies:

a.      Lighting:  Make sure corridors are well lighted.

b.      Nightlights:  Use of night-lights can aid in better vision in the middle of the night.

c.      Throw rugs:  either pull-up or secure rugs down with 2-way carpet tape.

d.      Clutter:  Reduce clutter to at least have clear walking paths.

e.      Low-toilets:  Use raised commode seat and/or install grab bars.

f.        Cabinets:  Store items in lower areas or redesign cabinets to be lower or accessible without need o step stool.

g.      Low seats:  Replace furniture with furniture that has a higher seat to floor height or have one chair that has a seat to floor height that you can rise from without difficulty.

h.      Heavily padded plush carpet:  This type of carpet disrupts proprioception or one’s ability to feel placing one at greater risk for falls.  Replace with low-pile rug, tile or wood. 


A physical or occupational therapist can perform a home safety assessment.  There are often different community groups that offer home safety assessments as well. 


Fall Prevention strategies

In addition to checking out your medications and improving the safety of your physical environment,  physical therapy and/or exercise can greatly reduce your risk for falls.  Studies show that older adults with greater quadriceps strength show much reduce risk for falls than in older adults with lesser muscle strength in the same muscle groups.  General physical condition can affect your risk for falls.  It is very common for individuals to experience loss of balance and/or falls following prolonged bed-rest or hospitalization.  In these circumstances, not only do the muscles experience weakness and possibly atrophy, but the vestibular system is not as efficient when not challenged or stressed at all due to inactivity. 


Physical therapists can assess fall risk and design an exercise program aimed at reducing falls.  A physical therapist in addition to providing strength and flexibility training, can design a set of exercise progressions to improve center-of-gravity control in seated, standing and moving task situations.  Postural control strategies can be taught and postural reactions improved via stressing the balance systems via different positions and differing the base of support..  A physical therapist can also assess a person’s need for an assistive device or other adaptive equipment needed for improved function and safety. 


In closing, balance is a skill that can be restored or improved via specific exercises and activity.  Simple measures such as having a physician or pharmacist review prescription medications and assessing your environment also can aid greatly in reducing the overall risk for falls.

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