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    Move Forward Guide

    Physical Therapist's Guide to Falls

    Falls and a fear of falling can diminish your ability to lead a full and independent life. Although 1 in every 4 older adults falls each year, falling is not a part of normal aging. You have the power to reduce your risk of falls. A physical therapist can help you do so by:

    • Assessing your risk for falling
    • Designing an individualized plan for your fall-prevention needs
    • Helping you make your home as safe as possible
    • Educating you about the medical risk factors associated with falls
    • Providing you with appropriate exercises and balance training
    • Working with other health care professionals to address any underlying medical conditions that could increase your fall risk
    • Providing you with recommendations on appropriate community programs

     

    What Are Falls?

    A fall is defined as any event that leads to an unplanned, unexpected contact with a supporting surface, such as the floor or a piece of furniture, that is not the result of a push or shove or the result of a medical event, such as a heart attack or fainting.

    A near-fall is a stumble or loss of balance that would result in a fall if you were unable to catch yourself.

    There are lots of factors that can increase your risk for falls, including:

    • History of a previous fall
    • Being female
    • Having a sedentary lifestyle
    • Being in overall poor health
    • Recent hospitalization
    • Advanced age
    • Difficulty with walking or keeping your balance
    • Leg weakness
    • Becoming fatigued easily
    • Limited flexibility
    • Problems with your vision or skin (touch) sensation
    • Getting dizzy when you stand up from sitting or lying down (orthostatic hypotension)
    • Medical conditions such as heart disease, diabetes, stroke, Parkinson disease, or Alzheimer disease
    • Trouble with your memory and thinking
    • Joint pain or arthritis
    • Taking too many medications or taking certain types of medications
    • Depression and/or anxiety
    • Home hazards such as throw rugs, poor lighting, or a lack of handrails on stairs
    • Inappropriate footwear
    • Inappropriate use of a walker or a cane

    The more risk factors you have, the greater your risk of falling.

     

    How Is It Diagnosed?

    Unlike with other medical conditions, there is no single test that can predict a fall. Adults aged 65 years and older should be screened by their primary care provider on a yearly basis to help determine their risk for falling. Additionally, if you are worried about falling, have had a loss of balance, or have had a fall, you should see a physical therapist.

     

    How Can a Physical Therapist Help?

    A 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:

    • Review of your medical history
    • Review of your medications
    • Simple vision test
    • Home safety assessment
    • Simple test of your thinking abilities
    • Check of your heart rate and blood pressure measurements at rest and while you change positions (from sitting/lying to standing)
    • Foot and footwear assessment
    • Balance, strength, and walking ability assessment

    Based on the evaluation results, your physical therapist will design a plan that is tailored to your needs. Your treatment plan may include:

    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 as well as recover from a loss of balance, including exercises such as single-leg standing, or holding your balance while performing an action like reciting the alphabet.

    Walking and moving. A prescribed exercise program should include a walking program. However, starting a walking program with poor balance can actually increase your risk for falling. Talk to your doctor or a physical therapist before you initiate a walking program to make sure that it is the right choice for you.

    While working with a physical therapist, you may be asked to perform activities, such as:

    • Dance steps
    • Walking in circles
    • "Figure 8" exercises to strengthen the core abdominal muscles that help stabilize your body
    • Working through an obstacle course

    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 perform another task, such as counting backward, engaging in a conversation, or carrying a bag of groceries.

    Strength training. Strengthening is a key element of fall prevention and is very effective in preventing falls, especially when combined with balance exercises. Your physical therapist will design an individualized strengthening program that focuses on specific muscle groups to help improve your standing balance, your balance while walking, and your ability to recover from a loss of balance.

    Endurance training. Aerobic exercise is physical exercise of relatively low intensity and long duration; it can help improve almost every aspect of your health, especially your endurance. Your physical therapist can work with you to plan a safe aerobic program, such as a walking or an aquatic program, to address your specific needs. The program may start with as little as 10-minute sessions and progress to 30-minute sessions, as your endurance improves.

    Pain management. Pain management plays a crucial role in older adults’ risk for falling and quality of life. Certain exercises, such as strengthening and aerobic exercises, are appropriate interventions to relieve pain in addition to decreasing fall risk. Treatments need to be modified appropriately, depending on each individual’s source of pain. Physical therapy has been shown to help individuals reduce or eliminate their need for pain medication, including opioids.

    Education. Your physical therapist will take the time to explain how you can best manage your own risks for falling. Your therapist also may talk to you about the best activities to help maintain your quality of life, and offer educational resources, such as:

    Fear management. It is important for you to talk with your physical therapist about the fear you have of falling. The therapist will work with you to build your confidence and help you get back to the activities that you may be avoiding because you are afraid of falling. Your individual assessment can also identify the activities that you actually should avoid to stay safe.

    Community programs. Several community-based fall-prevention programs are 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
            • Exercise more to increase their strength and balance

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

    Personal recommendations. Your physical therapist can provide personal recommendations based on your condition and goals to help you:

        • Increase the safety of your home environment by making changes, such as removing throw rugs or clutter
        • Adjust how you complete your daily tasks to reduce your fall risk
        • Choose appropriate footwear
        • Learn about proper nutrition, improving your sleep schedule, and other general information that can help reduce your fall risk
        • Meet with other health care providers when appropriate
     

    Real Life Experiences

    Andrea is a 70-year-old newly retired newspaper editor who has been diagnosed with diabetes, diabetic neuropathy (numbness and poor sensation in her feet), high blood pressure, and osteoarthritis (OA) in her knees. She lives by herself, performs her own household chores, and drives her own car.

    During the past year, Andrea fell twice—once when she tripped on an accent rug at home, and once when she slipped on black ice on the sidewalk outside her apartment building. She received no permanent injuries from the falls, but her fear of falling has steadily increased since then.

    In recent weeks, Andrea has felt increasing pain in her right knee. Her physician refers her to a physical therapist.

    Andrea’s physical therapist conducts a full medical history, and asks her to describe her symptoms. In addition to describing her knee pain, Andrea reports her fall history, and says she is afraid that she might lose her balance and fall again. Her physical therapist asks Andrea what her goals are for physical therapy. She says that she wants to reduce her pain and improve her ability to walk.

    Her physical therapist screens her for fall risk and finds that Andrea:

    • Has difficulty rising from a chair
    • Is slow to turn from side to side when standing, or change direction when walking
    • Has trouble walking more than a short distance

    Andrea’s physical therapist determines that she is at risk for falling and proceeds with a further evaluation. He tests Andrea's vision, which is adequate with eyeglasses. He finds that her vital signs are normal. Andrea reports that she 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. A special sensory test finds that Andrea has lost some sensation in her feet due to diabetic neuropathy. She admits that she does not like to exercise and thinks that her knee pain is worse after exercise, so her physical activity level is low. Her physical therapist tells her that all of these factors contribute to her risk of falling.

    Based on the examination, Andrea’s physical therapist alerts her physician to the possibility that she might be taking too many medications, and reports that her neuropathy is worsening and her diabetes is not being controlled as well as it could be.

    Focusing on Andrea's knee pain and balance problems, her physical therapist instructs her in strengthening exercises and balance training in a standing position. He monitors her progress with the exercises he designs to address her unique condition, such as standing leg lifts, which he asks her to also perform at home, unless she has an increase in pain.

    As Andrea progresses, she practices walking forward, backward, and in a circle. Her physical therapist adds "dual-task" training to her treatments, such as talking while maintaining a certain walking speed.

    Over the next few weeks, Andrea increases the number of repetitions of her strengthening exercises, and begins to perform safe balance exercises at home that her physical therapist approves. She reports that her doctor has adjusted her medication, and she feels noticeably better. Her physical therapist adds a single-leg stance, chair rises, and “wall squats” to her routine.

    After several weeks of steady work, during which Andrea gains strength and feels increasingly confident in her movement, her physical therapist arranges for her to join a community exercise program. She completes her visits to the clinic; her physical therapist follows her progress via telephone.

    Just this week, Andrea reports by phone that she now attends exercise classes twice a week, and keeps up with the home-exercise program her physical therapist designed for her. She says she feels stronger and “more alive” than she has in years. She proudly states that she is now able to take walks around the block with her grandchildren—pain free and without any fear of falling!

    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 a fear of falling, and balance problems. You may want to consider:

    • A physical therapist who is experienced in treating people with neurological problems or treating the geriatric population. Some physical therapists have a practice with a neurological or a vestibular (balance) rehabilitation focus or run an interdisciplinary fall-prevention clinic.
    • A physical therapist who is a board-certified clinical specialist or who completed a residency or fellowship in neurologic physical therapy or geriatrics. This physical 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 therapists’ 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 a 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.

    American Geriatrics Society/British Geriatrics Society. AGS/BGS clinical practice guideline: prevention of falls in older persons. Accessed February 5, 2018.

    Centers for Disease Control and Prevention. Important facts about falls. Accessed February 5, 2018.

    Centers for Disease Control and Prevention. Important facts about falls. Updated February 10, 2017. Accessed February 5, 2018.

    Lusardi MM, Fritz S, Middleton A, et al. Determining risk of falls in community dwelling older adults: a systematic review and meta-analysis using posttest probability. J Geriatr Phys Ther. 2017;40 (1):1–36. Free Article.

    Nematollahi A, Kamali F, Ghanbari A, Etminan Z, Sobhani S. Improving balance in older people: a double-blind randomized clinical trial of three modes of balance training. J Aging Phys Act. 2016;24(2):189–195. Article Summary in PubMed.

    Phelan EA, Mahoney JE, Voit JC, Stevens JA. Assessment and management of fall risk in primary care settings. Med Clin North Am. 2015;99(2):281–293. Free Article.

    Avin KG, Hanke TA, Kirk-Sanchez N, et al. Management of falls in community-dwelling older adults: clinical guidance statement from the Academy of Geriatric Physical Therapy of the American Physical Therapy Association. Phys Ther. 2015;95(6):815–834. Free Article.

    Maidan I, Freedman T, Tzemah R, Giladi N, Mirelman A, Hausdorff J. Introducing a new definition of a near fall: intra-rater and inter-rater reliability. Gait Posture. 2014;39(1)645–647. Free Article.

    Goodwin VA, Abbott RA, Whear R, et al. Multiple component interventions for preventions falls and fall-related injuries among older people: systematic review and meta-analysis. BMC Geriatr. 2014;14:15. Free Article.

    Grabiner MD, Crenshaw JR, Hurt CP, Rosenblatt NJ, Troy KL. Exercise-based fall prevention: can you be a bit more specific? Exerc Sport Sci Rev. 2014;42(4):161–168. Article Summary in PubMed.

    Cadore EL, Pinto RS, Bottaro M, Izquierdo M. Strength and endurance training prescription in healthy and frail elderly. Aging Dis. 2014;5(3):183–195. Free Article.

    Ambrose AF, Paul G, Hausdorff JM. Risk factors for falls among older adults: a review of the literature. Maturitas. 2013;75(1):51–61. Article Summary in PubMed.

    El-Khoury F, Cassou B, Charles MA, Dargent-Molina P. The effect of fall prevention exercise programmes on fall induced injuries in community dwelling older adults: systematic review and meta-analysis of randomised controlled trials. BMJ. 2013;347:f6234. Free Article.

    Cadore EL, Rodríguez-Mañas L, Sinclair A, Izquierdo M. Effects of different exercise interventions on risk of falls, gait ability, and balance in physically frail older adults: a systematic review. Rejuvenation Res. 2013;16(2):105–114. Free Article.

    Abdulla A, Adams N, Bone M, et al. Guidance on the management of pain in older people. Age Ageing. 2013;42 Suppl 1:i1–i57. Article Summary in PubMed.

    Studenski S, Perera S, Patel K, et al. Gait speed and survival in older adults. JAMA. 2011;305(1):50–58. Free Article.

    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.

    Gschwind YJ, Kressig RW. Gait disorders and falls. GeroPsych. 2010;23(1):21–32.

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

    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 in PubMed.

    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.

    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.

    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.

    Shumway-Cook A, Baldwin M, Polissar NL, Gruber W. Predicting the probability for falls in community-dwelling older adults. Phys Ther. 1997;77:812–819. Free Article.

    *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.