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    Move Forward Guide

    Physical Therapist's Guide to Falls

    Falls can diminish your ability to lead an active and independent life. About one third of people over the age of 65 and almost half of people over the age of 80 will fall at least once this year. There usually are several reasons for a fall. Physical therapists can help you reduce your risk of falling by:

    • Assessing your risk of falling
    • Helping you make your home as safe as possible
    • Educating you about the medical risk factors linked to falls
    • Designing individualized exercises and balance training
    • Working with other health care professionals and community services to create programs for people who want to reduce their risk of falling

     

    What Are Falls?

    The reasons for falls are complex and include:

    • Being 80 years old or older
    • Leg muscle weakness
    • Difficulty with balance or walking
    • Vision problems (cataracts, macular degeneration, wearing bifocals)
    • Medical conditions that limit your ability to get around, such as Parkinson disease, stroke, or diabetes
    • Conditions that cause confusion, such as dementia and Alzheimer disease
    • Depression
    • Taking more than 4 medications at the same time or psychoactive medications (such as sedatives or antidepressants)
    • Using a cane or other walking device
    • Home hazards (throw rugs, pets underfoot)
    • Low blood pressure

    The more risk factors you have, the greater your risk. The factors associated with the greatest fall risk are:

    • A history of previous falls
    • Balance problems
    • Leg muscle weakness
    • Vision problems
    • Taking more than 4 medications or psychoactive medications
    • Difficulty with walking
     

    How Can a Physical Therapist Help?

    If you are worried about falling or if you recently had a fall, your physical therapist can conduct a brief check ("screening") of your fall risk. If the screening shows that you are at risk, the therapist will perform a thorough evaluation, including:

    • A review of your medical history
    • A review of your medications
    • A simple vision test
    • A home safety assessment
    • A simple screen of your thinking abilities
    • A check of your heart rate
    • Blood pressure measurements while you change positions (from sitting to standing)
    • Feet and footwear assessment
    • Assessment of any nervous system disorders, such as stroke or Parkinson disease

    The therapist also will:

    • Measure your leg strength, using simple tests such as timing how long it takes you to risk from a chair
    • Determine how quickly and steadily you walk
    • Assess your balance—for instance, by having you stand on one leg or rise from a chair and walk
    • Use special tests to measure your balance

    Based on the evaluation results, your physical therapist will design an exercise and training program to improve your balance and strength. A recent systematic review of many published studies found that exercise-based programs in the home or in group settings are effective in preventing falls. These programs are especially effective when balance exercises are performed in a standing position without using much arm support.

    Balance Training

    Balance training has been shown to be an important and effective part of falls prevention. Your physical therapist will design exercises that challenge your ability to keep your balance, including such exercises as single-leg standing.

    Walking and Moving

    When people walk very slowly or are unsteady, they are at risk of falling. Your physical therapist can improve your walking ability by having you do such activities as:

    • Dance steps
    • Walking in circles
    • "Figure 8" exercises to strengthen the core abdominal muscles that help stabilize your body
    • Obstacle courses

    Doing More Than One Thing at the Same Time—Safely

    Older adults who have difficulty walking and talking at the same time are at a higher risk of falling. To help increase your safety during daily activities, your physical therapist can design a "dual-task" training program. This kind of training will challenge you to maintain walking speed while you do another task, such as counting backwards, engaging in a conversation, or carrying a bag of groceries.

    Strength Training

    Strengthening exercises are a key element of fall prevention when they are done in conjunction with balance training. Your physical therapist will design strengthening exercises that focus on your leg and the muscles used in maintaining posture.

    Aerobic Training

    Aerobic exercise is physical exercise of relatively low intensity and long duration; it can help improve almost every aspect of your health. Walking is one of the safest forms of aerobic exercise, no matter what kind of problem you have. Once you have begun your strengthening and balance program, your physical therapist will know when you're ready to start aerobic exercise. Depending on your ability, the therapist might have you do three 30-minute walking sessions each week.

    Education

    Your physical therapist will take the time to explain to you how to best manage your own risks for falling. Your therapist also may talk to you about the best activities for you to do to maintain your quality of life.

    Fear Management

    It will be important for you to talk with your physical therapist about any fear of falling that you have. Your therapist will work with you to determine whether there are activities you should avoid. Your therapist also will work with you to determine whether your fear may be unfounded and whether there are activities that you should be doing to keep strong and help your balance.

    Community Programs

    Several fall prevention programs are being promoted by the Injury Prevention and Control Center of the Centers for Disease Control and Prevention in collaboration with the Administration on Aging. These programs help people:

    • Reduce their fear of falling
    • Set goals for increasing their physical activity
    • Make their homes more safe
    • Do more exercise to increase strength and balance

    These programs often are led by volunteer coaches. Your physical therapist may be involved in setting up one or these programs and can help you find programs in your area that would be best for you.

     

    Real Life Experiences

    Andrea T. is 70 years old and has diabetes, diabetic neuropathy (numbness and poor sensation in her feet), high blood pressure, and osteoarthritis in her knees. She lives by herself and takes care of her own household chores, driving, and shopping. Referred to a physical therapist for knee pain, she also is concerned about falling. Andrea's goals for physical therapy are to reduce her pain and improve her ability to walk.

    The therapist screens her for fall risk and finds that Andrea:

    • Had 2 falls within the past 12 months, but no serious injury
    • Has difficulty rising from a chair
    • Is slow to turn
    • Has trouble walking more than a short distance

    The therapist determines that she is at risk for falling and proceeds with further evaluation. He tests Andrea's vision, which is adequate with eyeglasses. Her vital signs are normal. Andrea is taking more than 4 medications—including 2 drugs for high blood pressure and other medications for diabetes, pain, and anxiety. Testing shows that she also has muscle weakness. The physical therapist uses a special sensory test and finds that she has lost some sensation in her feet due to neuropathy. She does not like to exercise and thinks that her knee pain is worse after exercise, so her physical activity level is low. All of these factors contribute to her risk of falling.

    Based on the examination, the physical therapist alerts Andrea's physician to the possibility that she might be taking too many medications. Because the therapist is concerned that her neuropathy is worsening and her diabetes is not being controlled as well as it could be, he also refers her to the physician for diabetes management.

    Focusing on Andrea's knee pain and balance problems, the physical therapist instructs her in strengthening exercises and balance training in a standing position. The therapist monitors her progress with such exercises as standing leg lifts in all directions, standing on her toes, and standing on her heels, which Andrea is instructed to do at home daily unless she has an increase in pain. As Andrea progresses, she practices walking forward, backward, and in a circle. The therapist includes "dual-task" training such as walking and talking while maintaining walking speed. She does balance exercises on the days when she does not visit the physical therapist, increases the number of repetitions of strengthening exercises, and adds single-leg stance, chair rises, and wall squats. Her home exercise program takes about 30 minutes, and physical therapy sessions take about an hour.

    After several weeks, Andrea's physical therapist arranges for her to join a community exercise program and follows her progress via telephone. Andrea reports that she is able to take walks around the block with her grandchildren.

    This story was based on a real-life case. Your case may be different. Your physical therapist will tailor a treatment program to your specific case.

     

    What Kind of Physical Therapist Do I Need?

    All physical therapists are prepared through education and experience to treat people who have falls and balance problems. You may want to consider:

    • A physical therapist who is experienced in treating people with neurological problems. Some physical therapists have a practice with a neurological or a vestibular (balance) rehabilitation focus.
    • A physical therapist who is a board-certified clinical specialist or who completed a residency or fellowship in neurologic physical therapy. This therapist has advanced knowledge, experience, and skills that may apply to your condition.

    You can find physical therapists who have these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.

    General tips when you're looking for a physical therapist:

    • Get recommendations from family and friends or from other health care providers.
    • When you contact a physical therapy clinic for an appointment, ask about the physical therapist's experience in helping people with falls and balance problems.
    • During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible, and say what makes your symptoms worse.
     

    Further Reading

    The American Physical Therapy Association (APTA) believes that consumers should have access to information that could help them make health care decisions and also prepare them for their visit with their health care provider.

    The following articles provide some of the best scientific evidence related to managing fall risk and preventing falls. The articles report recent research and give an overview of the standards of practice for treatment both in the United States and internationally. The article titles are linked either to a PubMed abstract of the article or to free full text, so that you can read it or print out a copy to bring with you to your health care provider.

    Studenski S, Perera S, Patel K, et al. Gait speed and survival in older adults. JAMA. 2011;305:50–58. Article Summary on PubMed

    Prevention of Falls in Older Persons AGS/BGS Clinical Practice Guidelines. Accessed April 19, 2010.

    Stevens J. Falls Among Older Adults: An Overview. Accessed March 24, 2010.

    Lord SR, Smith ST, Menant JC. Vision and falls in older people: risk factors and intervention strategies. Clin Geriatr Med. 2010;26:569–581. Article Summary on PubMed.

    Tinetti ME, Kumar C. The patient who falls: "It's always a trade-off." JAMA. 2010;303:258–266. Article Summary on PubMed.

    Gillespie LD, Robertson MC, Gillespie WJ, et al. Interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev. 2009(2):CD007146. Article Summary.

    Silsupadol P, Shumway-Cook A, Lugade V, et al. Effects of single-task versus dual-task training on balance performance in older adults: a double-blind, randomized controlled trial. Arch Phys Med Rehabil. 2009;90:381–387. Free Article.

    Sherrington C, Whitney JC, Lord SR, et al. Effective exercise for the prevention of falls: a systematic review and meta-analysis. J Am Geriatr Soc. 2008;56:2234–2243. Article Summary on PubMed.

    Muir SW, Berg K, Chesworth B, Speechley M. Use of the Berg Balance Scale for predicting multiple falls in community-dwelling elderly people: a prospective study. Phys Ther. 2008;88:449–459. Free Article.

    Silsupadol P, Siu KC, Shumway-Cook A, Woollacott MH. Training of balance under single- and dual-task conditions in older adults with balance impairment. Phys Ther. 2006;86:269–281. Free Article.

    Orr R, Raymond J, Fiatarone Singh M. Efficacy of progressive resistance training on balance performance in older adults: a systematic review of randomized controlled trials. Sports Med. 2008;38:317–343. Article Summary on PubMed.

    *PubMed is a free online resource developed by the National Center for Biotechnology Information (NCBI). PubMed contains millions of citations to biomedical literature, including citations in the National Library of Medicine's MEDLINE database.

    Authored by Tiffany Shubert, PT, PhD; APTA's Neurology Section; and APTA's Section on Geriatrics. Reviewed by the MoveForwardPT.com editorial board.

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