Falls are such common events for older people that it is easy to overlook their often very serious consequences for that person and their considerable cost to the country.
Falls are common in people aged 65 years and older and are the leading cause of injury in this age group.
Here are a few statistics to demonstrate the impact of falls:
· Falls are the leading cause of death due to injury among the elderly.
· 87% of all fractures in the elderly are due to falls.
· Falls account for 25% of all hospital admissions, and 40% of all nursing home admissions
· 40% of those admitted do not return to independent living; 25% die within a year.
Many falls do not result in injuries, yet a large percentage of non-injured fallers (47%) cannot get up without assistance. For the elderly who fall and are unable to get up on their own, the period of time spent immobile often affects their health outcome. Muscle cell breakdown starts to occur within 30-60 minutes of compression due to falling. Dehydration, pressure sores, hypothermia, and pneumonia are other complications that may result from a period of time immobile after a fall.
The following demonstrates the most common reasons for falling.
In addition, there are many risk factors that can lead to an increased likelihood of falling:
• Cardiac factors: Arrythmias, Congestive Heart Failure, hypertension
• Musculoskeletal factors: Using walker / stick, Difficulty rising from chair, Foot problems, Musculoskeletal pain, Chronic conditions ie neuromusculoskeletal conditions, lower limb weakness
• Metabolic factors: Diabetes, low body mass index, vitamin D deficiency
• Neurologic factors; such as age related slowed reaction times or other neurological conditions
• Psychological; Depression, fear of falling
• Sensory impairment; Reduced vision, Decreased hearing
• Other factors also include:
• History of falls or fractures
• Medications especially taking more than 4 prescription medications (cardiac meds, antihypertensive drugs, NSAIDs, antidepressants,
• Cognitive impairment / dementia
• Environmental factors
• Risky behaviours
• Inappropriate footwear
• Urinary incontinence
• Cancer
• Anaemia
• Recent discharge from hospital (within last month)
• Age over 80
• Past history of stroke: CVA / TIA, with up to 40% of people who have had a stroke have a serious fall within the next 12 months
Some of the above risk factors (e.g., reduced muscle strength and impaired balance and gait) can be modified using exercise, whereas others (e.g., poor vision, medication use) require different intervention approaches that may require advice from other members of the multidisciplinary team.
Falls can have serious consequences including trauma, pain, impaired function, loss of confidence in carrying out everyday activities, loss of independence and autonomy, and even death.
The economic cost of falls increases with fall frequency and falls are an independent predictor for admission to long-term care. Healthcare costs can be reduced if falls are reduced.
So, how can physiotherapy help with falls prevention? Exercise can prevent falls particularly in older people. People, even in their 90s, can improve their strength and balance to achieve stability and avoid falls. Strength, flexibility, balance and reaction time are considered the most readily modifiable risk factors for falls and these can all be addressed with the right exercise programme. Improving stability requires a specific, fully tested and safe exercise program and ongoing commitment by the older person to perform their exercise programme regularly. Greater relative effects are seen in exercise programmes that include exercises that challenge balance. At Platinum Physiotherapy, our falls prevention exercise programme is based on the Otago Exercise programme.
What is the Otago Exercise Programme?
The Otago exercise programme was designed specifically for falls prevention. The programme consists of leg muscle strengthening and balance retraining exercises which progressively increase in difficulty, plus a walking plan.
The exercises are individually prescribed and it has been demonstrated that these exercises have a better effect when delivered by a trained exercise professional, such as a physiotherapist or exercise physiologist.
Specific exercise examples that may be included in the programme are:
Sit to stand Backwards walking
Heel / toe walking Knee bends
Side stepping Hip abduction / extension
Heel / toe raises Hamstring curls
Single leg stand Neck and back flexibility
The rationale for the programme is that muscle strength, flexibility, balance and reaction times are the risk factors for falls considered the most readily modified and the exercises address these factors. Both leg muscle strength and balance must be maintained above the threshold level required to achieve stability, so the exercise programme must achieve this.
The strengthening exercises focus on major lower limb muscle groups:
Knee flexors, knee extensors and hip abductors, which are particularly important for functional movements and walking.
Ankle dorsiflexor and plantarflexor muscles, which are particularly important for recovering balance.
Ankle cuff weights can provide additional resistance to the knee flexors, knee extensors and hip abductors, whereas the ankle dorsiflexors and plantarflexors are strengthened using body weight alone.
The balance exercises used in the programme are dynamic as opposed to static. They can help to maintain balance but will also improve the recovery of balance.
In addition to the above strengthening and balance exercises, the Otago exercise programme incorporates a Walking Programme. This focuses on maintaining and improving cardiovascular fitness, leg strength and proprioception. It is important to remember that walking will not on its own result in a reduction in falls. Participants should aim for up to 30 minutes, walking at their usual pace, at least twice a week, if safe. The walking can be broken up into shorter sessions, for example 3 x 10-minute sessions if this is more appropriate.
In addition to the benefits of preventing falls, regular moderate physical activity can also result in lower death rates and improved physical and mental health, physical function, health-related quality of life, sleep, and sense of wellbeing. Exercising in a group environment within the falls prevention programme can also benefit individuals socially, who may otherwise feel isolated from their peers.
Is there any evidence?
So, now we know a little about the Otago exercise programme for falls prevention, it is also useful to understand a little of the research evidence that demonstrates that this is an effective way of preventing falls.
Research shows that the OTAGO exercise program was most effective in reducing fall-related injuries in those aged 80 and older and resulted in a higher absolute reduction in injurious falls when offered to those with a history of a previous fall. Falls prevention exercise programmes reduced falls resulting in fracture by 61% and reduced falls resulting in the need for medical care by 43% (El-Khoury, et al, 2013).
Research also shows that exercise can be used as a stand-alone falls prevention intervention or as a component of a multifaceted program. Multifaceted interventions can prevent falls in the general community, in those at greater risk of falls, and in residential care facilities. This can include addressing some of the other risk factors with regular medical reviews, assessing living environment and even basic advice such as correct footwear. All older adults who are at risk of falling should be offered physical therapy or an exercise program incorporating balance, gait, and strength training.
A Cochrane review (Gillespie et al, 2012) found that the number of fallers was reduced by 15% to 29% with group exercise containing multiple components, individual home-based exercise, or tai chi. In most studies, the exercise program was a minimum of 12 weeks with 30- to 90-minute sessions one to three times per week. Silva et al (2013) also provided research that demonstrated that exercise intervention to prevent falls is most effective if balance exercise is combined with other types of exercise, usually resistance training, and performed two to three times per week for more than six months.
At Platinum Physiotherapy, we have regular falls prevention classes that utilize all the above information and exercise focus, along with individual exercise programming in small group settings. If you think you could benefit from our classes now you know a little more about falls prevention, please do not hesitate to contact our team for more information.
Lets work together to prevent falls and improve lives.
