Balance and Fall Prevention
Michael Haberpointner, PT, DPT
Doctor of Physical Therapy
Active Life Physical Therapy, LLC
Port Ludlow, WA
October 2011
Balance and Fall Prevention
Two part lecture
1) How our balance system works
2) What you can do to prevent falls
Falls
•
1/3 of people over 65 fall each year5,6
•
Most common cause of injury death for 65+ 2
•
90% of hip fractures in older adults10
•
Most common cause of non-fatal injuries2
Vicious Cycle
Fall
↗
Imbalance
↘
←
Inactive
Balance Defined
•
Balance: Control of center of mass over
base of support (Shumway – Cook, 2001)14
•
Center of mass: Center point of each body
segment combined
•
Center of gravity: Vertical projection of
center of mass
•
Base of support: Area of object that is in
contact with the ground
Base of Support
Center of Mass
Balance: Control of center of mass
over base of support
Balance: control of center of mass
over base of support
Cane widens base of support
Types of Balance
•
Steady state (static) balance: Maintain stable
position in standing or sitting
•
Reactive balance: Recovering from an
unexpected perturbation
•
Proactive (anticipatory) balance: Activating
balance in advance
Types of Balance

Reactive balance (being nudged by someone)
Reactive Balance
Types of Balance
Proactive (anticipatory) balance: Reaching,
leaning, pulling
Balance Systems
Balance is a complex composite of multiple
body systems
Motor
Sensory
Cognition
Motor Systems

Musculoskeletal system: strength and
flexibility

Neuromuscular system: coordination of
movement
Sensory Systems

Peripheral input: Visual, vestibular (inner
ear), somatosensory (input from joint and
muscle receptors, auditory (hearing)

Central processing: Receives information
from periphery interprets it, and sends
commands to motor systems
Cognition

Multitasking and filtering out distractions
while maintaining balance
Sensory components of balance
•
Vision: Significant portion of balance is
dependent on vision. If we close our eyes,
we become reliant on our inner ear and
somatosensory (body) systems.
•
Somatosensory: What you body is telling
you. Receptors in your joints and muscles
are receiving information of where your
body is in space.
Vision
Somatosensory
Sensory components of balance

Vestibular system (inner ear): Semicircular
canals oriented in 3 different planes.

Vestibular system: Head movement displaces
fluid on hair cells within canals which excites
the vestibular nerve.

Auditory system: Small component of
balance (e.g. walking in a sound-proof room)
Inner ear
Inner ear
Body response to sensory input
Normal body response to perturbation
(pushing patient forward and back)
A)
Mild perturbation: Ankle response (push
patient forward, the calf muscles engage)
B)
Moderate perturbation: Hip response
(push patient forward, patient leans back)
C)
Large perturbation: Stepping response
(patient steps forward to avoid falling)
Ankle response
Dynamic Balance—Gait Analysis

Balance during gait is different than static
balance. The center of gravity does not
stay within the base of support. The body
is in a constant state of imbalance.

Once a step is initiated, gait is sustained
by momentum.
Gait Cycle
Age related changes to motor
components of balance

Decreased magnitude of muscle response

Increased reliance of arms
Age related changes to sensory
components of balance

Decreased visual, vestibular,
somatosensory (body awareness), and
auditory (hearing) function

Decreased ability to adapt responses (e.g.
using your inner ear and your feet
Walking on beach at night
Age related changes to cognitive
components of balance
Decreased overall attention capacity
 Decreased ability to multitask (e.g.
carrying a cup of water while walking)

Abnormal balance

As the balance system declines, so does
the ability of the system to respond
correctly

Individuals with an increased fall rate did
not use an ankle strategy 2
Abnormal balance
Cerebrovascular accident (CVA)—Stroke

A) Synergistic pattern: Groups of muscles
work together in a “stuck” pattern

B) Increased muscle tone

C) Cognition (e.g. impulsive behavior)

D) Impaired body awareness
Abnormal balance
Parkinson’s Disease
 A) Dynamic balance problem

B) Difficulty initiating gait

C) Moments of freezing during movement

D) Altered gait cycle
Abnormal balance
Benign Paroxysmal Positional Vertigo (BPPV)

A) Calcium crystals stuck in the semicircular
canals in the inner ear.

B) Dependent on head position.

C) Vertigo –sensation that the room is
spinning.
Inner ear
Abnormal balance
Orthopedic cases: (Hip or knee replacement)

A) Impaired joint range of motion (alters
center of mass during gait and stance)

B) Altered body awareness (new body part)
Balance tests
Berg Balance scale:
 Discriminates older adults at risk for falls 14

Single best predictor of fall status in
community dwelling adults

Sound test with good reliability

Mainly tests static and anticipatory balance
Berg Balance Scale
Sitting to standing
 Standing unsupported
 Standing to sitting
 Standing unsupported with eyes closed
 Standing unsupported with feet together
 Reaching forward with outstretched arm
 Pick up object from floor
 Turning to look over right and left shoulder
 Turn 360 dg
 Step on step stool (# times in 20 seconds)
 Tandem stance;
Standing on one foot

Balance Tests – Berg Balance Scale
14 item scale for possible 56 points total
•
Decrease in Berg score = increased fall risk14
•
Score of 56-54, 1 point drop = 3-4% inc. fall risk
•
Each point drop from 54-46, = 6-8% increase
•
Below 36, fall risk = 100%
•
Limitations: does not test reactive balance;
ceiling effect
Balance Tests
Timed up and go test12
• Get up from seated position, walk 3 meters,
turn around, walk back to chair
• Adults who took > 30 sec were dependent
in activities of daily living
Functional reach test
• Standing reaching forward with hand
• Highly predictive of falls among older adults3
Functional Reach Test
Balance Tests
Nudge test:
• Moving patient forward, back, sideways
•
Ankle vs hip, vs stepping strategy
•
Test under different conditions: soft surface,
eyes closed, with head movements
Other tests:
• Hallpike - Dix (testing for vertigo),
observational gait analysis, dynamic gait index
Balance Tests
Treatment of Balance

Restoring ankle function and muscle
facilitation with electrical stimulation

Restore normal ankle response

Nintendo Wii fit—balance training system

Gait training
Treatment – Shin Stimulation
Nintendo Wii Fit System
Treatment of balance
Exercise examples
 A) Calf stretch

B) Heel / toe raises

D) Soft surface stance in corner

E) Sitting to standing
Summary of Balance Systems
Evaluation to Treatment
Falls

1/3 of people over 65 fall each year5,6

In 2008, 82% of fall deaths people 65+2

Average hospitalization cost $17,500.1013

By 2020, annual direct & indirect cost of
fall injuries is expected $54.9 billion4
Vicious Cycle
Fall
↗
Imbalance
↘
←
Inactive
Fall Prevention

Please pick up packet “What you can do
to prevent falls” by the Centers for
Disease Control and Prevention.
1)Begin a regular exercise program
2)Have your doctor review your medicines
3)Have your vision checked
4)Make your home safer
Falls Risk Factors

Risk factor: puts you at risk for falling

Intrinsic risk factors + extrinsic risk
factors = FALLS
(Clare Morrison, MCSPT 2006)
Intrinsic Risk Factors
Within the individual
• Age
• Being female or male
• Previous fall
• Impaired balance
• Lower body weakness
• Taking more than 4 medications
• Neuropathy; more than one chronic
disease
Extrinsic Risk Factors
Person’s environment:
 Uneven surfaces
 Obstacles, stairs, curbs
 Poor lighting, sudden changes in lighting
 Slippery surfaces
 Poor footwear
 Poorly fitted assistive devices for walking
Extrinsic Risk Factors
Falls Risk Factors
Cognition / Mental Health
 Depression
 Anxiety
 Cognitive impairments / Dementia

*One or more of the above increases fall
risk.
Sally York, MN, RNC 2006
Modifiable Risk Factors
Risk factors you can change

Lower body weakness

Gait problems

Impaired gait (walking)

Taking > 4 medications
Non Modifiable Risk Factors
Risk factors you cannot change
Age
 Sex
 History of falls
 Disease state

Most Common Falls Risk Factors
According to U.S. Department of Health
and Human Services
1) Muscle weakness *
2) History of falls
3) Gait deficit *
*modifiable risk factors
Falls Risk Factors
Risk of falls dramatically inc. as the
number of risk factors inc. (Tinetti 2003)15

8% in older adults with no risk factors

78% in older adults with 4 or more risk
factors
Senior Falls Prevention Study
WA Department of Health Study (2006)
key findings
 Older adults are often unaware of their
health, medications, and overall risk of
falling.
 It takes a fall for an older adult to be
concerned about falls.
 Health care providers “don’t ask” and
older adults “don’t tell” about falls.
Senior Falls Prevention Study
Senior Falls Prevention Study
WA DOH Study (2006) continued:

Older adults will reduce modifiable risk
factors if they get information from their
health care provider and if they have
access to fall prevention information.
What You Can Do To Prevent Falls
1)Begin a regular exercise program
2)Have your doctor review your medicines
3)Have your vision checked
4)Make your home safer
1. Start a Regular Exercise Program
U.S Surgeon General’s Recommendation
 30 min / day (break it up 10 min per session)
6 days of the week.
 Moderate intensity activity / week
Examples of moderate intensity activity
 Gardening 25 min, Walk 2 miles in 30 min
 Swimming laps or water aerobics for 20 min
**Start slow. Something is better than
nothing.
1. Start a Regular Exercise Program
Start a Regular Exercise Program
Moderate intensity:You can still carry on
a conversation while you exercise
 Start at a slow pace: 5-10 minutes a day
 Wear sturdy shoes
 Drink plenty of water
 Walking indoors (mall) or w/ a friend
 Stop exercising if you experience
shortness of breath, chest pain, dizziness

1. Start a Regular Exercise Program
Start a Regular Exercise Program
Key Components of exercise program
1)Endurance
2) Strength ≥ 2x per week
3) Balance ≥ 2x per week
4) Flexibility
Start a Regular Exercise Program
Strengthening guidelines:
 No pain during exercise

Normal: muscle soreness & mild fatigue

Slow, steady movements

Do not hold breath (breathe out with effort
and in as you relax)
Start a Regular Exercise Program
Balance exercise guidelines:

Safely: Your back to a corner & chair in front

Someone present

Go slow. If dizzy sit down
Start a Regular Exercise Program
Start a Regular Exercise Program
Stretching guidelines:
Slowly get into position
 Gentle, hold stretch for 15-20 seconds
 Avoid bouncing movements

*check with PT what exercise is
appropriate for you. Everyone is different.
Have Your Medications Reviewed
2. Have your Medications Reviewed

Older adults who take 4 or more meds are
at increased risk of falling16

Aging and new health conditions can change
how medications affect you

Medication problems can happen easily in
adults who have difficulty paying for meds

People living alone can have med problems
Have Your Medications Reviewed
Medication safety rules (WA State DOH)

Keep current, dated list of ALL meds w/ you

Follow instructions for taking meds

Read and keep a copy of prescription info

Create a system and regular routine
2. Have your Medications Reviewed
Medication safety rules (WA state DOH)
 Provide complete medical history to provider

Provide complete list of ALL meds

Tell your provider how you usually take meds

Discuss concerns about medication cost

Ask what the meds are for & side effects

Take notes
2. Have your Medications Reviewed

Get your prescriptions filled at the same
pharmacy. This allows pharmacist to identify
potentially dangerous drug interactions.

Think teamwork:Your Doctor, Physician
Assistant, Nurse Practitioner, Pharmacist,
Hospital Staff, and You.
3. Have Your Vision Checked

Have your vision checked by an eye doctor
at least once a year

Poor vision can increase your fall risk

Check with local Area of Aging for vision
care assistance program

Check your hearing: Adjustment period for
hearing aids 2-4 weeks
4. Make your home safer
Most people fall at home8

55% inside house

23% outside, but near house

22% away from home
4. Make your home safer
4. Make your home safer
Negative stigma of home safety
 Associated with “old age”

Visibility (grab bars, ramps)

People will accept some modification
recommendations, but not all

Old habits are hard to change
4. Make your home safer
No cost home modifications
• Clutter removal form stairs & walkway
•
Rearranging furniture and cords
•
Cleaning walkways
•
Remove throw rugs (or use double sided tape)
•
Place items on lower shelf
•
Put phone within reach of floor
4. Make your home safer
Low cost home modifications:
• Replace burned out light bulbs
• Install night lights
• Non-slip rubber bathmats or self stick strips
• Replace home footwear (non-slip, non-stick)
• Elevated toilet seat
• Carpet firmly attached to every step
• Fire alarms. Emergency response systems
4. Make your home safer
Assistance with modifications:
•
•
•
•
•
•
Rail installation both sides of indoor /
outdoor stairways
Grab bars around toilet and in tub / shower
Ramps if stairs are a problem
New lighting fixtures
Lights at top & bottom of stairs w/ switches
*Boeing Blue Bills—assistance w/ installation
4. Make your home safer
Other modifications:

Fix loose handrails

Place lamp next to bed and within reach

Nightlight from bed to bathroom
4. Make your home safer
Other safety recommendations
• Use brighter light bulbs
• Paint contrasting color on top edge of steps
• Keep emergency #’s in large print near phone
• Put phone on floor in case you fall
• Talk to your neighbor
• Clean up spills immediately
• Never brace on towel bar
4. Make your home safer
Other safety recommendations
 Run electric cord against walls, never under
rugs or across doorways

Do not step over sleeping pets

Water heater below 120 dg F (burns can
startle and cause falls)

Get up slowly after you sit or lie down
4. Make your home safer
What you can do to prevent falls
1)Begin a regular exercise program
2)Have your doctor review your medicines
3)Have your vision checked
4)Make your home safer
Special Thanks to: Wellness Committee
Resources
Active Life Physical Therapy Port Ludlow:
www.activelifetherapy.com
 Home Instead Senior Care
www.homeinstead.com/650/Pages/HomeInsteadSeniorCare.aspx
 Olympic Area Agency on Aging: www.o3a.org/
 ECHHO: http://echhojc.org/
 Boeing Bluebills Olympic Peninsula:
www.bluebills.org/olympic.html
 Centers for Disease Control and Prevention www.cdc.gov/
 National Osteoporosis Foundation » http://www.nof.org/
 American Physical Therapy Association: www.apta.org
 WA State Dept. Of Health www.doh.wa.gov/
 Washington State Falls Prevention web site
www.fallsfreewashington.org

References

1. American Geriatric Society, British Geriatric Society, American Academy of Orthopedic
Surgeons Panel on Falls Prevention. Guidelines for the Prevention of Falls in Older Persons. JAGS
49: 664-672, 2001.

2. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control.
Web–based Injury Statistics Query and Reporting System (WISQARS) [online]. Accessed
November 30, 2010.


3. Duncan P, Studenski S, Chandler J, Prescott B. Functional Reach: a new clinical measure of
balance. J Gerontol 1990; 45M192-M197.


4. Englander F, Hodson TJ, Terregrossa RA. Economic dimensions of slip and fall injuries. Journal of
Forensic Science 1996;41(5):733–46.trial. The Gerontologist 1994;34(1):16–23.


5. Hausdorff JM, Rios DA, Edelber HK. Gait variability and fall risk in community–living older adults:
a 1–year prospective study. Archives of Physical Medicine and Rehabilitation 2001;82(8):1050–6.

6. Hornbrook MC, Stevens VJ, Wingfield DJ, Hollis JF, Greenlick MR, Ory MG. Preventing falls
among community–dwelling older persons: results from a randomized trial. The Gerontologist
1994:34(1):16–23

7. Issue Brief (Public Policy Inst (Am Assoc Retired Pers) 2002 Mar;(IB56):1-14.

8. Kochera A. Public Policy Institute, American Association of Retired Persons, Washington, DC,
USA. Falls among older persons and the role of the home: an analysis of cost, incidence, and
potential savings from home modification. 2002.
References

9. Morrison, C. Northwest Orthopaedic Institute. Proven Best Practices: Assessment and
Treatment of Patients Who are at Risk for Falls. Gentiva Seminar. Attended October 20,
2006.


10. National Hospital Discharge Survey (NHDS), National Center for Health Statistics.
Available at: www.cdc.gov/nchs/hdi.htm. Assessed September 14, 2011.


11. National Fire Safety Council, Inc., Michiagan Center, MI 49254-0378. Falls Prevention:
Protecting Your Active Lifestyle.

12. Podsiadlo D, Richardson S. The timed “Up and Go” test: a test of basic functional
mobility for frail elderly persons. J Am Geriatr Soc 1991; 39:142-148.

13. Roudsari BS, Ebel BE, Corso PS, Molinari, NM, Koepsell TD. The acute medical care costs
of fall-related injuries among the U.S. older adults. Injury, Int J Care Injured 2005;36:1316-22.

14. Shumway-Cook A, Woollacott M. Motor Control Theory and Practical Applications, 2nd
Ed. Lippincott Williams & Wilkins. Baltimore, MD 2001.

15. Tinetti ME. Clinical Practice. Prevention Falls in Elderly Persons. N Eng J Med 2003;
348:42-49
References

16. Washington State Department of Health: Senior Falls Prevention Study 2006

17.York, S. Northwest Orthopaedic Institute. Proven Best Practices: Assessment and
Treatment of Patients Who are at Risk for Falls. Gentiva Seminar. Attended October 20,
2006.