Steady On Your Feet
Balance and Fall Prevention
By Steven Halperin, PT

Most of us take balance for granted in our own lives and in the lives of the people around us. We think about balance only when a client falls, and then only in terms of filling out paperwork or deciding on the proper treatment or restraint. If pressed, most of us would have trouble defining balance - what makes good balance and what happens when balance declines, leading to falls and loss of independence. To fully serve our clients, it is essential that we learn about balance and how to reduce our client's risk of falls.

What is balance? Balance is the ability to maintain the body's center of mass over its base of support (shumwayCook & Woollacott, 2001). Good balance exists because multiple body systems interact flawlessly and automatically, providing accurate and exact feedback to our nervous system. Sensory inputs from touch, pressure, pain, sight, and sound flow into the central nervous system are processed at multiple locations in the brain. Motor commands that originate in the brain move rapidly down motor nerves to the muscles that control movement. Voluntary motor commands are relatively slow, those that control automatic movements are faster, and those that control reflexes are lightening quick.

To maintain proper balance, our nervous system instantaneously processes, assesses, and reassesses motor and sensory input. Information about the strength, force, timing, and speed of movement is rapidly processed. Sensory information from receptors in the eyes, inner ears, joints, muscles, and skin provide important sensory information for balance. Cognitive factors such as fear of falling and dementia, the effects of medications, and our general medical condition affect balance. Determining the cause of a balance disorder requires knowledge of each of these systems and the ability to identify the factors that contribute to the balance deficit. A thorough balance evaluation looks systematically at each of these factors and directs the examiner to an effective and specific treatment plan.

As balance becomes gradually more impaired, the risk of falling increases. Falls are a major problem in older adults and in those with neurological disorders. Healthcare professionals should routinely ask older clients whether they have fallen within the last year and the circumstances and frequency of the falls. Advancing age and multiple impairments (and medications used to treat those impairments) increase risk of falls. Most falls occur when walking, and 53% are due to tripping.

To give you an idea of the incidence of falls, as of 2007 data, in people 65 years and older falls are the leading cause of injury deaths and the most common cause of nonfatal injuries and hospital admissions for trauma. Each year in the United States, nearly one third of older adults experience a fall. In 2003 more than 13,700 people 65 years or older died of fall-related injuries. Another 1.8 million were treated in emergency rooms for nonfatal injuries related to falls (NCIPC, 2006).

Fall prevention takes a combination of medical treatment, rehabilitation, and environmental changes. The most effect interventions address multiple factors. These interventions include:

- Assessing the client after a fall to identify and address risk factors and treat the underlying medical conditions.

- Making changes in the nursing home environment to make it easier for residents to move around safely, including installing in grab bars, adding raised toilet seats, lowering bed heights, and installing handrails in the hallways.

- Reviewing prescribed medicines to assess their potential risks and benefits and to minimize use.

- Providing clients with hip pads or protectors, which can effectively prevent most hip fractures if a fall occurs.

- Using devises such as alarms that go off when the client tries to get out of bed or move without assistance.

- Designing exercise programs that can improve balance, strength, walking ability, and physical functioning among nursing home residents.

Vertigo and dizziness may be a cause of falls. An estimated 90 million Americans experience dizziness at least once in their lifetime. For patients over 75 years of age, dizziness is the number one reason for visiting a physician and is a significant factor for falls in elderly individuals. One form of dizziness is a condition known as benign paroxysmal positional vertigo. There are other forms of dizziness such as Meniere's Disease, vestibular neuritis, labyrinthitis, perilymphatic fistula and acoustic neuroma.

The most common cause of BPPV is head injury in people under 50 years. In older adults it is the degeneration of the vestibular system of the inner ear. Essentially what happens is that small stones move into canals of the inner ear and cause an imbalance in sensory input into the central nervous system. The end effect is when one moves their head there is a mismatch between sensory and motor impulses, which causes dizziness.

In order to properly diagnose this condition, a complete evaluation is performed, including a visual motor assessment that measures the inner ear/eye connection, balance assessments utilizing standardized tests, vertigo assessment, and physical therapist-designed exercise-movement programs. Treatments include vestibular habituation/adaptation exercises, balance and proprioceptive exercises, strengthening exercises and gait training exercises, as well as a personally designed home program.

For more information on vestibular/balance rehabilitation program, please contact Steven Halperin, PT at 516-582-2216 IMAGE