2. DEFINITION
•An event that results in a person’s inadvertently
coming to rest on the ground or lower level with
or without loss of consciousness of injury.
•This excludes falls from major intrinsic event
(seizure, stroke, and syncope) or overwhelming
environmental hazard.
3. PREVALENCE
• Falls are extremely common among the elderly
population accounting for substantial morbidity and
mortality.
• Approximately, 30 percent of people over the age of
65 fall each year.
• In about 3 percent of falls, the older adult lies on the
floor for at least 20 min.
4. RISK FACTORS
• Risk factors associated with the occurrence of falls in elderly
are classified as (i) intrinsic or host factors and (ii) extrinsic or
environmental factors.
I. Intrinsic factors
• – Poor balance
• – Weakness
• – Foot problems
• – Visual impairment
• – Cognitive impairment
6. • A number of factors were associated with an
increased risk of falling including reduced physical
activity, reduced proximal muscle strength and
reduced stability while standing.
• Other significant factors included arthritis of the knees
and impairment of gait, hypotension and the use of
psychotropic drugs.
7. THE ROLE OF BALANCE CONTROL
It may be recalled that normal postural control is composed
of three components:
1. Sensory input continually provides information about the
body’s position and trajectory in space. Sensory data critical to
balance comes from visual, vestibular and somatosensory
input.
2. Central processing can be regarded as the process of
“setting up” the postural response. It involves sensory cortex,
frontal and motor cortex, brainstem, basal ganglia and
cerebellum.
8. 3. Effector output constitutes the biomechanical
apparatus through which the centrally programmed
response is carried out. It involves upper and lower
motor neurons, muscles and joints.
9.
10. ASSESSMENT AND EVALUATION
• History
A. Circumstances of fall: Includes
1. Environmental circumstances: Including location, floor
surface, lighting, quality of chair.
2. Direction: Forward falls typically indicate a trip whereas
backward falls usually indicate a slip.
• Tripping falls may occur because of impaired depth perception or
poor foot clearance. Backward falls may suggest CNS disease with
a lesion in cerebellum,brainstem or basal ganglia.
11. 3. Activity at the time of fall: Helps in understanding
the cause of fall. For example, a fall while rising from a
chair indicates muscle weakness or nervous disease.
4. Recent meal or alcohol intake: For example, a fall
occurring 30 minutes after a meal may be due to
postprandial hypotension.
12. B. Associated symptoms: For example,
lightheadedness, vertigo, weakness, confusion,
palpitations
C. Relevant comorbid conditions: For example, prior
stroke, cardiovascular disease, parkinsonism,
osteoporosis, anaemia, diabetes mellitus, depression,
anxiety, cognitive impairment.
D. Previous falls
13. E. Review of current as well as past medications,
particularly those having hypotensive or psychoactive
effects.
Drugs:
14. Physical evaluation
– Vision: Visual impairments related with the occurrence of
falls include poor distant vision, decreased visual field,
reduced contrast sensitivity, impaired depth perception and
cataract.
Therefore, the visual examination should include
i. assessment of visual fields – Confrontation test
ii. Visual acuity - assessment of distant vision with or without
distance lenses – using Snellen’s chart
17. • Sensory assessment
• Superficial Sensation – light touch and pain sensations
• Proprioceptors - Romberg's test
• Romberg test: The patient is instructed to stand with the
feet together for 10 sec, first with the eyes open and then
with eyes closed. Grading is simple: able or not able to
complete the task.
18.
19. Vestibular function: Vestibular dysfunction related with the
occurrence of falls includes classic symptoms of vertigo or
dizziness.
The examination should include
1. Head-thrust test: The patient is asked to look at the
examiner’s nose while the examiner rapidly move the
patient’s head to the right and left. Small, rapid eye
movements indicate a positive head-thrust test.
21. The corrective saccade indicates a deficient
VOR(Vestibulo-ocular reflex) on the same side of the
head turn, indicating a peripheral vestibular lesion on
the same side.
22. 2. The Dix-Hallpike maneuver: (Posterior Canal BPPV)
A positive response is indicated by nystagmus and
vertigo lasting for 10-30 sec and reproduced within a
few seconds of rapidly positioning a patient from
seated to supine with the head turned 45°.
3. Supine Head-Roll Test – for Lateral canal BPPV
24. BPPV (Beningn Paroxysmal Positional Vertigo)
• Free floating densities (canaliths) located in semi-circular
canals deflect the cupula creating the sensation of vertigo.
• Although These canaliths are most commonly located in
the posterior SCC, the lateral and superior canal may also
be involved.
• Complaints:
oVertigo with change in head position,rolling over or getting
out of bed, and it is often side specific.
oVertigo occurs suddenly and lasts for less than 1 minute.
26. Cardiovascular function:
• Pulse and BP
• Cardiac arrhythmias
• Orthostatic hypotension
-- Orthostatic hypotension (OH) is defined as a postural
reduction in systolic blood pressure (BP) of ≥ 20 mm Hg
or diastolic BP of ≥ 10 mm Hg, measured within 3
minutes of rising from supine to standing.
27. Musculoskeletal function
• ROM
• Arthritic changes
• Leg length discrepancy
• Skeletal deformities such as genu varus or valgus
• Muscular weakness
• Foot problems - arthritis, peripheral neuropathy(diabetes)
28. – Neurological function
• Sensations, particularly touch, kinesthesia and
proprioception
• Reflexes
• Muscle tone
• Cortical, cerebellar and extrapyramidal tract functions
29. • Cognitive function: Mini Cog test
• Functional Balance Assessment :
-BERG BALANCE SCALE
-TINETTI TEST (POMA) – Performance-Oriented
Mobility Assessment
-FUNCTIONAL REACH TEST
30.
31.
32.
33. TREATMENT
The treatment is based on following principles:
1. • Identification and treatment of underlying
reversible deficits
2. • Identification and compensation for irreversible
deficits
3. • Prevention to reduce repetition of incidence and
fear of falling
34.
35. • Fludrocortisone, a corticosteroid, is used to help control the
amount of sodium and fluids in your body.
• It is used to treat Addison's disease and syndromes where
excessive amounts of sodium are lost in the urine.
• It works by decreasing the amount of sodium that is lost
(excreted) in your urine,therefore it increases blood pressure
and volume.
• Fludrocortisone is considered the first‐ or second‐line
pharmacological therapy for orthostatic hypotension
alongside mechanical and positional measures such as
increasing fluid and salt intake and venous compression
methods.
37. Pertubations
a. With the patient’s feet shoulder width apart, attempt to gently disrupt
the patient’s balance.
b. With the patient’s feet shoulder width apart, attempt a larger
disruption of the patient’s balance.
c. With narrow BOS – gentle disruption and then progress to larger
disuption
c. With the patient standing heel to toe, attempt to gently disrupt the
patient’s balance.
d. With the patient standing on a balance beam, attempt to gently
disrupt the patient’s balance.
e. Restrict the patient’s ankle mobility with a brace or tape. Attempt to
gently disrupt the patient’s balance.
f. Repeat a to c on a soft foam surface.
38. With Normal and Narrow BOS
a. Eyes open on a stable surface.
b. Eyes closed on a stable surface.
c. Eyes open on a thick foam surface.
d. Eyes closed on a thick foam surface.
e. Eyes open on a rocker board.
f. Eyes closed on a rocker board.
g. Repeat tasks a to f while simultaneously rotating or
tilting the head.
39. SINGLE LEG STANCE
a. Single-leg stance with eyes open (left and right)
b. Single-leg stance with eyes closed (left and
right)
c. Single-leg stance, performing tubing-resisted
shoulder horizontal abduction, unilateral and
bilateral
d. Single-leg stance, performing tubing-resisted
shoulder flexion from 120 to 180 degrees of
overhead flexion, unilateral and bilateral
40. e. Single-leg stance, performing tubing-resisted hip
extension
f. Single-leg minisquats with the contralateral knee
flexed
g. Single-leg minisquats with the contralateral knee
extended and hip flexed
h. Single-leg minisquats on a minitramp
i. Single-leg toe raises from a level surface
j. Single-leg toe raises from the edge of a step
41. MINI TRAMPOLINE ACTIVITIES
a. Single-leg minisquats on a minitramp, with tubing
around the posterior knee pulling the knee into flexion
b. Single-leg minisquats on a minitramp, with tubing
around the medial knee pulling the hip into abduction
c. Single-leg minisquats on a minitramp, with
tubingaround the anterior knee pulling the knee into
extension
d. Single-leg minisquats on a minitramp, with tubing
around the lateral knee pulling the hip into adduction
42. a. Repetitive single-leg hopping with arms free
b. Repetitive single-leg hopping with arms across the
chest
c. Repetitive single-leg hopping with arms overhead
d. Rope jumping on alternate feet
e. Rope jumping on a single foot
f. Single repetition of a single-leg hop, controlling and
stopping the landing as quickly as possible (i.e., hop
and stop)
g. Hop and stop on a minitramp
