Why Patients are Falling for Physical Therapy

As physical therapists, we are familiar with treating multiple musculoskeletal impairments, ranging from neck pain to back pain to joint injuries. As a profession, we are also familiar with one subset of individuals in particular: the geriatric population. Although we may see our geriatric patients for a variety of issues, there is one issue that our older patients have in common: Falling As per the CDC, every year around 30 million older adults falls. This horrifying number leads to 30,000 deaths each year. You read that last line correctly. 30,000 deaths. Every. Year. On top of this, the CDC states that every year 3 million older adults are hospitalized are treated for falls every year as 1 out of every 5 falls leads to a serious injury. Falls are the number one reason for hip fractures in older adults each year, leading to hip replacements and ORIF placements.

Geriatric falls are also the number one reason why our patients lose their independence as they age, which leads to them leaving their homes to live in facilities such as skilled nursing facilities and assisted living facilities. Falls in this population not only mean the loss of independence in the sense of just living alone, but can also stop them from taking part in hobbies that bring them joy and meaning such as sports (think gold, jogging, bowling, tennis, and many others!), gardening, and even something as simple as shopping for their own clothes and groceries. Falls can lead to social isolation which can lead to a variety of psychosocial concerns such as depression, and anxiety.

However, there is good news! Most falls are 100% preventable! How you may ask? That’s where we come in. As physical therapists, we are in the perfect position to help our geriatric patients, and keep them from falling.

How do we know though? Unfortunately many of our patients are not seen as “at risk” for falls until they actually suffer one!

Therefore, it is of the utmost importance that PT’s all, at the minimum, screen their patients for fall risk even if that is not the primary reason that we are seeing them!

In this article, I will be briefly going over what balance is, and how we as physical therapists can assess it in order to ensure our geriatric patients live full, independent and successful lives.

What is balance?

Obviously, “balance” is quite the broad term. So what exactly does this word mean? When searching the term in the Merriam-Webster dictionary, the first definition reads as “a: Physical Equilibrium” and “b: The ability to retains one balance”. Not particularly helpful for us at physical therapy. However, when you ask the PT experts (such as every physical therapy students best friend Susan B. O’Sullivan) you get a far more useful meaning. O’Sullivan in her text “Physical Rehabilitation” defines balance as followed:

As a physical therapist, this makes much more sense to me! SO for our intents and purposes, balance is the ability to keep your COM (your head and torso) over your BOS (your feet)! Balance can be further explained using the following four terms: Dynamic Balance, Static Balance, Feed-Forward and Feed-Back Control.

Static balance is your ability to keep your COM within your BOS while not moving. Think of individuals who are standing in place as well as sitting upright which is just as important! Dynamic balance is an individuals ability to keep their COM within their BOS while moving, such as while walking, running, as well as while participating in sports!

Feed-Forward control and Feed-Back control are both very important control mechanisms for balance in our patients. Feed-Forward control is when a person uses sense such as vision in order to create a motor plan to keep their balance. Think of someone preparing to walking on a sandy beach or over an icy puddle. Feedback control is when your body must contend with an unexpected perturbation or loss of balance. This situation would look like an individual being bumping into while walking at a crowded supermarket or someone stepping on an object, which unexpectedly causes them to lose their balance.

All four of these aspects of balance are extremely important in the assessment and treatment of balance dysfunction. Not only does one need to keep ones balance in day to day mobility such as walking and stair negotiation, but static balance activities such as sitting upright for long period can be just as vital as walking, And in some situations, training people to deal with unexpected obstacles to their balance can be ever more important then helping them with “planned” pertubations.

Now that the question of “What is balance” is answered, now we can dive into what actually goes into a proper balance assessment.

Assessment of Geriatric Balance

When we think of balance, many believe they are treating the “balance” system and the balance system only. However, Our sense of balance is actually broken up into numerous upon numerous of different systems including our special senses, sensations from muscles and joints, vestibular system, cognitive factors, psycho social factors any many more. However, in order to assess our patients, it is best to think of balance as a 3 part system that all work together in order to improve our ability to remain upright. Those three most important systems are the visual system, somatosensory system, and our vestibular system.

Somatosensory

The somatosensory system plays an extensive role in our balance system, is basically what we mean when we think of our patients “sensation” . Our somatosensory system main role is basically to collect information from our muscles, joints, as well as a variety of receptors of the skin in order to help tell the body where it is in space. Under the umbrella term of somatosensory are a variety of other sensations that are imperative for maintaining upright balance. These include but are not limited to proprioception, tactile , vibration, protective sensation and many others. In order to truly assess our patients risk of falls, it is important to look at a variety of sensations in order to rule out sensation loss as a possible contributing factor to their fall risk.

One of the most important “sensations” in the somatosensory system is proprioception. Proprioception is our body’s way of know just where it is in space. This is obviously important when we think of locomotion training such as foot placement, obstacle clearance, and just knowing where your feet are! Patient’s who experience a loss of proprioception can find it necessary to look at their feet whenever they walk or else they “do not know where t her feet are”. Other deficits in proprioception can be a slowed walking speed (as the need more concentration) as well as a sensation of “walking on sand” or another uneven surface. Thankfully, proprioception is quite easy to assess!

In order to assess proprioception, I generally educate my patient on the procedure and ask them to close their eyes. I then grab their great toe with two fingers, one on each side of their MTP joint. Then, making sure that you are not touching any other part of their foot, you move their MTP joint up and down. When you stop moving the joint, simply ask the patient if their toe is pointing up or down. If they cannot discern the position, they most likely have a deficit in proprioception. I generally do this three times on each foot in order to decrease the chances of the patient guessing the correct answer. It is always important to take other factors into account such as patient cognition and language barriers in order to ensure they understand the exam.

Tactile sensation is another important aspect of the somatosensory system to assess during you evaluation. Tactile is responsible for, as you may guess, telling the CNS about what kind surface the foot may be coming into contact with. This is important because if we have a deficiency in tactile sensation, we may be unable to ascertain when damage is being done to our feet. This leads into another very important sensation called protective sensation. Protective sensation is used to prevent injury to the foot in the form of pressure ulcers among other injuries. This very common amongst individuals with uncontrolled Type 1 and 2 Diabetes, commonly termed as diabetic neuropathy. In order to test tactile sensation, or specifically light touch tactile sensation, I generally educate my patient on the procedure, then ask them to close their eyes. I then to proceed to lightly brush their lower extremities with either my finger or a pen, and generally follow a dermatomal pattern. I generally ask the patient to not only respond with “yes” when they feel the touch, but also report to me where they are feeling it for example, “left upper thigh”. Protective sensation is measured via the use of monofilaments. A10g monofilament is placed at the bottom of the great toe being tested. The PT then places a very gentle pressure on the monofilament, just enough to make it bend. The patient then reports whether or not they can feel the sensation of touch. If they cannot, then they have absent protective sensation and are at more risk for pressure injuries of the foot.

Vibration sense is another important sensation to address while performing your somatosensory screen. Vibration can be thought as of the “canary in the coal mine” of somatosensory loss. This is because it is generally the first sensation to show sings of degradation. Even though a patient may have perfect tactile sensation and proprioception, you may find on a screen that their vibration is altered, in which case the patient and physician should be educated and on the watch for further sensation loss in the future.

In order to assess vibration, a 128hz tuning fork is required. First, educate the patient on the importance of the procedure, then have them close their eyes. Then gently hit the tuning fork in order to create the vibration, and place it against the patients lateral MTP joint of the great toe. I generally ask the patient to tell me “when it begins, and when it ends”. The norm for vibration sense varies depending on the source, but you could always document this as impaired, absent, or normal. A study I found by Appaswamy Thirumal Prabhakar et. Al, 2019 states that >8s would be considered normal

Vision

The visual system is another incredibly important system that plays a large role in balance. The role of the vision system in balance is to provide visual-spatial information from the environment to the CNS. This can include depth perception in order to discern how far away certain obstacles may be, identification of different possible hazards, as well as changes to the environment. Vision is also extremely important to feed-forward control and motor planning!

It is always important to keep vision in mind for another reason. Many individuals with somatosensory deficits and use vision in order to compensate. I have had many clinics in my own clinic walking in perfectly fine, but to lose their balance immediately once they close their eye to perform a MCSTSIB or Fukuda marching test.

Of course, if you believe your patient is suffering from an undiagnosed visual impairment, it is always necessary to refer them to the proper health care practitioner such as an ophthalmologist. However, physical therapists can play an important role in screening for possible vision deficits in order to rule in or rule out whether vision is the main issue.

Physical Therapists can screen visual acuity using a traditional snellen chart, as well as a assessment of peripheral vision. Screening for oculomotor deficits can also shed some light on possible visual deficits that can open a window into other CNS issues or vestibular issues such as the H-Test and testing of other ocular movements.

A thorough history is also very important during a vision screening! Learning about your patients PMH and complaints can help lead you into what direction their impairment may be going, as well as help you decide which health care practitioner to best refer out to! It is also helpful in discerning what is “fixable” by a physical therapist, and when it is important to focus on treatment of other areas.

Screening for visual deficits and referral to the right resources can be vital in the prevention of future falls! Remember, many falls occur in the home, and especially in the evening when the patient is ambulating in a minimal light environment. This is a situation where being visually dependent can lead to a possible catastrophe.

Vestibular System

The vestibular system is another system that is extremely important to assess while screening and assess your patient for possible balance dysfunction. The vestibular systems role in balance is to give you brain constant feedback about the heads position in relation to the rest of the body. It is also important because of something called the Vestibulo-Ocular Reflex or VOR. The purpose of the VOR reflex is to keep your eyes focused on a specific target or object as your head moves. Deficits in the VOR system can lead to a sensory mismatch leading to dizziness as well as a feeling of disequilibrium.

Although the vestibular system plays the smallest role in maintaining our balance while we are ambulating and standing on a stable surface. That actually changes drastically once we are put into an unstable environment. Once in an unstable environment, The vestibular system becomes the most important system in sending information to the CNS regarding our position in space.

Like many other systems, the VOR reflex and vestibular system naturally degrade as we age, so it is very common to see these deficits in older adults.

Thankfully, the VOR is quite easy to assess in clinic. One way is you use a Dynamic Visual Acuity test or DVA. In this test, a Snellen chart is necessary. The patient is placed in front of a Snellen chart and asked to read as far down as they can. Afterwards, the clinician takes the patient’s head in their hands and rotates the head at a speed of two hertz. The patient is then asked to read down as far as they can while their head is moving. If there is a difference of three or more lines, the VOR reflex is considered abnormal.

Other exams that can be used to identify a potential VOR dysfunction or vestibular weakness are the Head Impulse Test and Fukuda Marching test.

Recent research has also pointed out another vestibular impairment that is increasingly common in the geriatric community, Benign Paroxysmal Positional Vertigo or BPPV. BPPV occurs when otoconia, which are calcium carbonate crystals, in the Utricle of the inner become displaced into one of the 3 semicircular canals. This displacement can cause a variety of symptoms, most common being a sense of true, room spinning vertigo with position change (most commonly lying down with the head extended.) However, those in the geriatric community may not experience the usual vertigo symptoms common in this condition. In the geriatric community BPPV can manifest itself as a sense of disequilibrium or imbalance.

Thankfully, BPPV can be simple to diagnose and treat. In order to identify the most common form of BPPV, that of the posterior semicircular canal, a physical therapist can use the Dix-Hallpike test. If positive, the patient will exhibit upbeat torsional nystagmus of the eye, which exhibits quick, twitch like beatings of the eye. If BPPV of the posterior canal is found, it can be treated using the Epley maneuver, a canalith repositioning treatment or CRT. For more information regarding the diagnosis and treatment of BPPV, please refer to resources such as Vestibular.org for more information.

Outcome Measure

In order to further assist you in your screening and assessment of geriatric patient for balance dysfunction, there are a variety of outcome measures you can use in order to discern their risk of fall status. The Timed Up and Go test is an extremely common assessment used in order to assess fall risk. The test is timed, and consists of the patient standing up from a chair with armrests, walking forward 10 feet around a cone, and then returning to the seat to sit down. This test is fast, easy to use and can give you great information regarding a patients gait characteristics and especially their dynamic stability while turning. Another test that can be used is the Five Times Sit to Stand test, in which the patient is timed for how long it takes them to sit up and sit down five times from a chair, or the 30 seconds Sit to Stand test, in which the patient has 30 seconds to sit up and down as fast as they can. Both of these serve as functional measures of bilateral lower extremity strength, which has shown to also be a big factor in fall risk. Other outcome measurements that are common in balance assessments are the BERG, Functional Gait Assessment or FGA, as well as the Dynamic Gait Index or DGA. For more information on these outcomes, the Shirley Ryan Ability lab is a fantastic resource for new grads, students, and experienced clinicians alike. Although these outcome measures are an important component of fall risk assessments, it is very important to realize that only performing an outcome measure does not replace or constitute a fall risk assessment. Dysfunctions within the balance systems are multifactorial, and therefore a comprehensive look at the different systems of balance must be evaluated in order to get the “full picture” of what is going on with a patient.

Geriatric falls are currently one of the greatest threats facing the aging population, leading to a slew of health problems, hospitalization, surgeries and deaths every year. Unfortunately, many individuals go undiagnosed for risk of falls until they in fact suffer one, which in many instances are too late. A majority of falls can be avoided how ever with proper precautions and treatment and specific deficits. As physical therapists, we are in the perfect position to screen, assess, and treat our patients with balance dysfunctions. In our roles of Doctors of Physical Therapy, we can play a vital role in the prevention of future falls in our patients, and quite possibly save their lives in the process!

^{Works Cited}

1. ^{“AbilityLab Home.” Shirley Ryan AbilityLab, www.sralab.org/.}
2. ^{Burke, Christina. “Postural Control 1.” Postural Control I. Postural Control I, 2017.}
3. ^{Burke, Christina. “Postural Control II.” Postural Control II. Postural Control II, 2017.}
4. ^{Burke, Christina. “Vestibular System.” Vestibular System. Vestibular System, 2017.}
5. ^{Kaleda, Mary Jo. “Late Adulthood Falls.” Late Adulthood Falls. Late Adulthood Falls, 2017.}
6. ^{O'Sullivan, Susan B., et al. Physical Rehabilitation. F.A. Davis Company, 2014.}
7. ^{Prabhakar, Appaswamy Thirumal, et al. “Timed Vibration Sense and Joint Position 6. Sense Testing in the Diagnosis of Distal Sensory Polyneuropathy.” Journal of Neurosciences in Rural Practice, vol. 10, no. 02, 2019, pp. 273–277., doi:10.4103/jnrp.jnrp_241_18.}
8. ^{“Vestibular Disorders Association.” Vestibular Disorders Association, vestibular.org/.}