Preventing Falls in the Elderly: The Effects of Therapeutic Exercise and Balance Retraining Diana Coburn

Introduction Nearly one-third of elderly adults experience a fall in the United States, every year and about one out of ten falls among the elderly results in a serious injury, such as hip fracture or head injury that will require hospitalization. Not only do these individuals suffer physical pain but they also experience emotional pain and the average time required to recover in a long-term care facility is one year. According to the Centers for Disease Control, many of these elderly never return home (1). The Centers for Disease Control stated that in 2010 falls were responsible for 1) 21,700 deaths; 2) 258,000 hip fractures of which 95% of them were caused by falls; 3) 2.3 million nonfatal fall injuries among older adults were treated in emergency departments and more than 662,000 of these patients were hospitalized; and 4) the direct medical costs for caring for this type of injury was $30 billion. (1). Physical therapy plays a central role in prescribing exercises for the prevention of falls. Choosing the right prescription for each client is part of health care reasoning and enables therapists to take the best-judged action for individual patients. Physical therapists considered 5 primary factors when making exercise prescriptions. They were as follows: client goals, client perceived problems, functional problems, therapist perception of clients adherence to exercise and therapist perception of clients safety with exercise (2). Falls in older adults are known to be multifactorial, and fall risk is dependent on a combination of factors including: neurological (peripheral/central nervous systems), musculoskeletal system and cardiopulmonary system. These fall risk factors can differ substantially from individual to individual (3). In a study done on patient education, evidence shows that one-to-one patient education appears to be effective as a part of a multiple intervention fall prevention program (5). The purpose of this case report is to describe an inpatient plan of care for physical therapy to improve a patients balance and gait stability to prevent her from being a future fall risk. Case Description The patient was a 75 year-old female with a history of falls, who fell while trying to get to the bathroom at her cousins house. The patients recollection of the incident was poor and did not remember if she lost consciousness or not. Instead of opening the bathroom door she opened a door that lead to the stairs and she fell down. When her husband found her, she was awake on the floor and he assisted her back into bed. The next morning, the patient was taken to the emergency room where she was admitted. Preliminary blood results indicated the patient was hypoglycemic and she was given glucose. She was otherwise stable. The patient had been previously sedated with Vicodin upon arrival to the emergency room. Upon initial examination, the patient had bruises over her body, but x-rays were negative for fractures. In addition, a work up for syncope was performed and came back negative, but an MRI revealed a mild brain injury secondary to her fall.

Prior to her fall, the patient ambulated with a cane and/or forward wheeled walker when she was out in the community or held onto her husbands arm for security. The patient was independent with all activities of daily living and lived in a travel trailer with her husband that had three steps to enter. In addition, the bathroom had grab bars and she used the walls and countertop for stability when needed. The patients present and past history included: Type I diabetes; over sedation with pain medications; mild cognitive impairment; hypertension; deep vein thrombosis; mild stroke 15 years ago, and left patellar fracture 10 years ago. Examination The following examination was performed by the physical therapist upon admission to the acute care unit within the hospital. Range of Motion Strength Right Upper Extremity Strength Left Upper Extremity Strength Right Lower Extremity Strength Left Lower Extremity Sensation Coordination Bed Mobility Not taken secondary to pain 4/5 4/5 4-/5 4-/5 Light touch lower extremities intact Finger to Nose: Within Normal Limits Rolling: Standby Assistance Scooting: Minimum Assistance of one person Supine to Sit: Stand by Assistance Sit to Supine: Stand by Assistance Sit to Stand Transfers: Stand by Assistance Stand to Sit Transfers: Stand by Assistance Bed to Chair: Stand by Assistance Good Good Good Fair Stand by Assistance: for 200 feet with a Forward Wheeled Walker Alert and oriented to person, place and time Consistently Normal/Intact Normal /Intact Normal/Intact

Transfers

Static Sitting Balance Dynamic Sitting Balance Static Standing Balance Dynamic Standing Balance Ambulation Mental Status Follows Commands Vision Hearing Communication

Interventions After examining the patient, the patient and physical therapist discussed therapy and the following goals for discharge were agreed upon by both the therapist and patient. Discharge Goals: To be met in 5 days 1. 2. 3. 4. Patient will ambulate for 300 feet with at least modified independence. Patient will be independent with bed mobility. Patient will be independent with transfers. Patient will increase strength to 4+/5 in upper and lower extremities.

The patient was admitted to the acute care rehabilitation unit for rehabilitation after being admitted to the emergency department. The patient was seen three times a day for a total of 180 minutes a day for 6 days including 60 minutes of physical therapy, 60 minutes of occupational therapy, and 60 minutes of speech therapy. The initial plan of care set by the physical therapist consisted of bed mobility, transfer training, gait training, balance reeducation, strength training, family training, discharge planning and equipment needs. Bed Mobility On day one the patient was instructed in the logroll technique, with the head of bed slightly elevated, requiring hand held assistance, and minimal assistance to clear feet off of the bed, to transfer from supine to upright sitting position at the edge of bed, secondary to muscle soreness throughout her body. On day 2 the patient was able to come to an upright sitting position at the edge of bed with stand by assistance and verbal cues for sequencing. On day 3 the patient was able to come to an upright sitting position independently, requiring more time than normal for transfer. On day 4 the patient was sitting upright in her wheel chair upon arrival. Transfer Training The patient required minimal physical assistance to transfer from sitting at the edge of bed to her forward wheeled walker but maximal verbal cues, demonstrational cues, and tactile cues for sequencing and safety. By day 4 the patient was transferring with no physical assistance and minimal verbal cues for sequencing. Training was progressed by asking the patient to explain the sequence of events for safe transfers from sitting to standing and standing to sitting with the forward wheel walker and by varying transfer surfaces from level to non-level surfaces. The patient demonstrated fair to good carryover.

Gait Training Gait training was performed initially with a forward wheel walker and a wheel chair follow, with contact guard assistance with an antalgic gait, shorted stride bilaterally, occasional loss of balance and scissoring (exaggerated when turning) and a slow cadence. The patient required moderate verbal cues and demonstration for step through gait pattern and proper step width, over 3 trials of 12 feet, 100 feet and 200 feet with seated rest breaks in between on the first day. Gait training was progressed by providing fewer verbal cues and demonstration, then asking the patient to verbalize how she would proceed with ambulation, especially during turns. The patient participated in stair training ascending step over step with one handrail. By the last day the patient was ambulating up to 300 feet. with a forward wheeled walker, contact guard assistance and minimal verbal cues, demonstrating fair to good carryover. The patient participated in stair safety training including ascending with a handrail step through gait and descending with bilateral handrail and a step to gait secondary to anxiety related to recent fall. The patient required minimal assistance ascending the stairs and maximum assistance while descending the stairs due to fear of going down the stairs after her fall. Balance Reeducation Balance reeducation began with activities in sitting, reaching out of center of mass to tap a balloon back and forth, with wide base of support progressing to narrow base of support and standing on a foam pad requiring her to reach out of her base of support while using ankle, hip and stepping strategies. The patient participated in standing balance activities with a forward wheel walker contact guard assistance and wide base of support while bouncing a balloon with a light weight racket progressing to narrow base of support and no forward wheeled walker. The patient demonstrated stepping strategies while kicking a light weight ball against a wall with forward wheeled walker and contact guard assistance progressing to no forward wheeled walker. The patient demonstrated balance control by rolling herself around on stool with stand by assistance arms outstretched and wide base of support at the feet progressing to arms folded at the chest and narrow base of support at the feet. The patient demonstrated modified tandem walking with and without forward wheeled walker, retro walking, walking with eyes closed, with cervical spine rotations and elevations, while talking, side stepping over cones with and without holding a glass of water all with contact guard assistance and country dancing with her husband hand in hand and hand on waist. Strength Training Exercises were performed in standing at the hemi bars for stability. The exercises were demonstrated for the patient when needed and moderate to minimal verbal cues were

provided during exercises in order to maintain proper form. The exercises were demonstrated bilaterally and included hip flexion, heel raises, hip abduction, hip extensions 2 x 15 progressing to 2 x 20 and 2 x 20 with 2 lb. cuff weights, toe raises 2 x 15 progressing to 3 x 20 seated with red theraband for resistance, Mini squats 2 x 15 and 2 x 20, hip circumduction forward and retro 2 x 15 progressing to 2 x 20, and sit to stand transfers x 5 progressing to 10. Patient/Family Training The patient was educated on stair safety, gait safety, and transfer safety. The patient was educated on standing slowly to avoid dizziness, to keep the small light above her stove on at night to provide light when needing to use the restroom, to remove rugs and other trip hazards, to use the handrail on the side of the travel trailer before stepping onto the stairs, to be extra cautious when taking pain medications and to check her blood sugar regularly. The patient and husband were encouraged to continue with the hobby of country dance lessons. The patient was encouraged to participate in outpatient balance training and encouraged to use her forward wheeled walker when not in her trailer. The patients husband was given instructions on how to guard the patient with a gait belt during ambulation with a forward wheeled walker while they were in the hospital so they could walk in the halls over the weekend. He was instructed to let the nursing staff know when they would be walking. He was also instructed to watch her feet to make sure that she was not scissoring. Outcomes The following outcomes reflect the patients status upon discharge from the acute rehabilitation unit after five days of therapy. Range of Motion Strength right ankle within normal limits, left ankle lacking 3 degrees from neutral in dorsiflexion Patient can perform 2 x 20 of the following standing, bilateral lower extremity exercises with a 2 pound cuff weight, hip flexion, heel raises, hip abduction, hip extensions, hip circumduction with no weight, seated toe raises with red theraband for resistance, and 2 x 20 minisquats. Light touch lower extremities intact Finger to Nose: Within Normal Limits Rolling and Scooting: Independent Supine to Sit: Stand by Assistance with Minimal verbal cues for safety Sit to Supine: Stand by Assistance with minimal verbal cues for safety Sit to Stand Transfers: Stand by Assistance

Sensation Coordination Bed Mobility

Transfers

Static Sitting Balance Dynamic Sitting Balance Static Standing Balance Dynamic Standing Balance Ambulation Mental Status Cognition Short Term Memory Follows Commands Vision and Hearing Communication Discussion

Stand to Sit Transfers: Stand by Assistance Bed to Chair: Stand by Assistance with minimal verbal cues for safety Normal Good Good Good with forward wheeled walker Standby Assistance: for 300 feet with a Forward Wheeled Walker Alert and oriented to person, place and time Later found to be slightly confused secondary to hitting her head in the fall. Difficulty with short term memory Consistently Normal/Intact Normal/Intact

This patients case is an excellent example of a physical therapy plan of treatment that reduced her risk of falling again. The patient was provided with six days of physical therapy, occupational therapy, and speech therapy for 60 minutes each. Physical therapy focused on lower extremity strength training, increasing range of motion, gait training, practicing safe transfers, fall prevention education and balance training. Occupational training focused on upper extremity strength and transfers, and speech therapy focus on cognitive impairments. The patient increased her lower extremity strength as seen by her ability to perform more repetitions with two pound ankle weights added, her reaction time with external perturbations seemed to increase although no objective means of measuring the speed were available they were observed. The patient responded to blocked and serial practice for sequencing during safety training with transfers requiring less verbal cues as the days progressed. She and her husband were educated on how to make their trailer safer and how to ambulate in the community safely and transfer safely. The cumulative losses after falls can be devastating. The identification of potentially preventable or modifiable risk factors should be a high priority. In randomized, controlled trials, the rate of falling has been reduced by up to 40 percent among the elderly living in the community. The preventative strategies tested in these trials, include adjustments in medications, exercise regiments, and behavioral recommendations, and could be readily incorporated in to the care of the elderly living in the community (6).

The first goal of physical therapy for elderly patients who are at risk of falls is to prevent them and the resulting sequelae from occurring. Evidence has shown that an education program provided to patients upon entering a hospital proved to reduce the number of falls by 45 percent (4). There are many factors that contribute to falls. Some of those factors can be improved upon. Each individual is unique pertaining to the factors that contribute to their fall risk. An assessment of the risk of falls is the first step in providing quality therapy for the patient. Evidence shows that these categories should be considered in the assessment of an elderly patient at risk for falls. They include both intrinsic and extrinsic factors (7). 1. Intrinsic a. Cognitive Impairment b. Peripheral Sensory Loss c. Slowed Central Processing d. Muscle Weakness e. Balance and Gait Impairments f. Range of Motion 2. Extrinsic a. Environmental Hazards b. Change in Medications c. Social Setting d. Busy Environments (7) The next step in providing quality therapy for the elderly patient according to research is a multidimensional exercise program. After assessing the varied systems that contribute to being a fall risk, a program can be prepared that includes these factors. A study on the effects of a multidimensional approach was successful in improving mobility and balance, in turn reducing the risk of falling (8). Conclusion The patient in this case study was an example of how physical therapy interventions can benefit elderly individuals who fall. The key elements that have been covered in this case report are: education is an important first step in fall prevention, assessment of systems (intrinsic factors) and extrinsic factors are the natural next step in providing a program that best meets the individual needs of each patient. Balance retraining is an ongoing process that encompasses a lifestyle change. Adherence is the last key, without continued practice of the individually outlined programs the effects of therapy will diminish over time. All of these key elements are part of a multidimensional approach to providing a physical therapy program.

References 1. National Center for Injury Prevention and Control. (2008). Preventing Falls: How to Develop Community-based Fall Prevention Programs for Older Adults. Atlanta, GA: Centers for Disease Control and Prevention. Retrieved November 2, 2013, from http://www.cdc.gov/homeandrecreationalsafety/images/cdc_guide-a.pdf 2. Romi Haas, Stephen Maloney, Eva Pausenberger, Jennifer L. Keating, Jane Sims, Elizabeth Molloy, Brian Jolly, Prue Morgan and Terry Haines. (2012). Clinical Decision Making in Exercise Prescription for Fall Prevention. PHYS THER. 92:666-679.

3. Ankur Desai, Valerie Goodman, Naaz Kapadia, Barbara L. Shay and Tony Szturm. (2010). Relationship between dynamic balance measures and functional performance in community-dwelling elderly people. Physical Therapy. 90, 748-760.

4. Terry P. Haines, Keith D. Hill, Kim L. Bennell and Richard H. Osborne. (2006). Patient education to prevent falls in subacute care. Clinical Rehabilitation. 20, 970-979. 5. Falls Among Older Adults: an Overview. Retrieved November 2, 2013, from http://www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html 6. Mary E Tinetti, M.D., and Christianna S. Williams, M.P.H. (1997). Falls, Injuries Due to Falls, and the Risk of Admission to a Nursing Home. Massachusetts Medical Society. Vol. 337 number 18. Retrieved November 3, 2013, from http://www.sph.umd.edu/adv/papers/Efft_Falls_TM_NEJM_1997.pdf 7. Peggy R. Trueblood, PhD, PT. Assessment of Balance and Gait in the Older Adult at Risk for Falls in the Clinical Setting. Retrieved November 2, 2013, from http://www.fresno.ucsf.edu/norcal/downloads/10trueblood%20assessment%20of%20b alance%20gait%20in%20older%20adult%20(main%20lecture%203-16-11).pdf 8. Anne Shumway-Cook, William Gruber, Margaret Baldwin and Shiquan Liao. (1997). The Effects of Multidimensional Exercises on Balance, Mobility, and Fall Risk in CommunityDwelling Older Adults. PHYS THER. 77:46-57.