No full-text available
To read the full-text of this research,
you can request a copy directly from the author.
Abstract
Slips and falls are major causes of accidents and injuries at work, in public areas and at home. Studies have shown that the more risk factors an individual is exposed to, the higher risk for slips and falls. The aim of this paper is to describe risk factors for slips and falls, methods that can be used in prevention, and ideas on how physiotherapists can work with prevention of slip and fall accidents. A review of the literature has been done, searching for relevant literature published in English between 1985 and 2000, from the Medline catalogue. The result showed many different risk factors for slip and fall accidents: (a) transfer situations; (b) reduced postural control, i.e. disturbed balance together with reduced muscle strength in the lower extremity; (c) reduced mobility in the hips and feet; (d) dizziness and vestibular asymmetries; and (e) medication. The following diseases may increase the risk for slip and fall accidents: stroke, cardiovascular diseases, musculoskeletal disorders, depression, Parkinson's disease, diabetes and dementia. Preventive interventions have been described but more are needed. A standardized fall anamnesis has been described including patients' earlier fall accidents and relevant risk factors present. Walking ability, balance, medicine consumption can be registered. Preventive programmes concerning risk factors for slips and falls, physical activities for daily use, and preventive aids have been developed and can be recommended for use by patients visiting primary health care and occupational health care. Studies have shown that physical training can increase the number of activities in daily life, reduce the use of technical aids, increase balance and walking ability, which all reduce the risk for slip and fall accidents.
... According to Hara et al. (1997) the people were not satisfied with the performances of the anti-slip devices. Methods to test anti-slip devices and assessments of anti-slip devices has been made identifying effective devices (Gard andLundborg, 2000, 2001;Gard, 2000;Gard and Berggård, 2006). An intervention study was conducted in the USA during the winter 2003/2004 among 109 fallprone respondents aged 65 and above. ...
... According to Hara et al. (1997) the people were not satisfied with the performances of the anti-slip devices. Methods to test anti-slip devices and assessments of anti-slip devices has been made identifying effective devices (Gard andLundborg, 2000, 2001;Gard, 2000;Gard and Berggård, 2006). An intervention study was conducted in the USA during the winter 2003/2004 among 109 fallprone respondents aged 65 and above. ...
Pedestrians slipping and falling is a major safety problem around the world, not least in countries with long winters such as Sweden. About 25000-30000 people need medical care every year for treatment of fall injuries in Sweden. Use of appropriate shoes and anti-slip devices are examples of individual measures that have been suggested to prevent slipping and falling. An intervention study was performed during the period February to April 2008. The study, which focused on healthy adults in northern Sweden, examined the effect of using anti-slip devices on daily walking journeys and prevention of slip and falls. The respondents were divided into three groups: an Intervention Group, a Control Group, with similar distribution of gender and age, and a Comparison Group. Four questionnaires were distributed: (1) background, (2) daily diary of distance walked and occurrence of incidents or accidents reported weekly, (3) detailed incident or fall report and (4) experiences of using anti-slip devices for those who used these devices during the trial period. Half of the respondents stated that they had previous experience of using anti-slip devices. In this study, 52% of the respondents used anti-slip devices. Anti-slip devices improve the walking capability during wintertime. Among those using appropriate anti-slip devices, the average daily walking distance was found to be statistically significantly longer compared to people not using anti-slip devices. This study indicates that an increase in daily walking distance can be made without increasing the risk of slips/falls when using anti-slip devices. The study also indicates that by using appropriate anti-slip devices and having information about when and where to use them, based on their design, people avoid having slips and falls. The respondents experienced in using anti-slip devices in this study will continue to use them and will also recommend others to use anti-slip devises.
The interest for effective preventive strategies for slips and falls is growing. Much remains to be done, however, to prevent slips and falls in the traffic environment. Using an appropriate anti-slip device may reduce the risk of slips and falls on different surfaces outdoors during winter. The aim of this study was to evaluate the best anti-slip devices of different designs in the Swedish market on a larger group of healthy individuals in different ages on five different slippery surfaces as a way to develop a standard method to test anti-slip devices. Three different designs of anti-slip devices: heel device, foot-blade device and whole-foot device were evaluated on ice surfaces uncovered or covered with gravel, sand, salt or snow. The evaluations were done according to subject's perceived walking safety and balance, videorecordings of walking postures and movements, time to take on and off each anti-slip device, advantages/disadvantages with each anti-slip device and a list of priorities for own use according to three criteria: safety, balance and appearance. The heel device was perceived to be the most safe on all five surfaces, followed by the toe device and the whole-foot device. The heel device was also perceived to be the one with the best walking balance on uncovered ice and on snow covered ice. There were some significant differences due to gender and age. Most subjects walked with a normal muscle function in the hip and knee when walking with or without an anti-slip device on all surfaces. The heel device was perceived as the most rapid one to take on and the toe device as the most rapid one to take off. All three devices were perceived as having a good foothold. The heel device was perceived to fit the shoe and to be stable at heel-strike. The toe device was easily portable and stable on uncovered ice. The whole-foot device was comfortable to walk with and safe on snow covered ice. The heel device had the highest priority according to walking safety, walking balance and choice for own use.
To determine the frequency of and risk factors fo falls and injurious falls in the noninstitutionalized elderly, the authors conducted a follow-up study of 409 community-dwelling persons aged 65 years or more in west-central Montreal, Quebec, Canada, from May 1987 to October 1988. Following an initial at-home interview, each subject was telephoned every 4 weeks for 48 weeks for collection of data on falls experienced since the last contact. Each of the 12 follow-up interviews was completed by at least 90% of the subjects eligible for interview. Data were also collected in the follow-up interviews on time-varying exposures. Twenty-nine percent of the subjects fell during follow-up; 17.6% fell once, and 11.5% fell two or more times. The incidence rate for falls was 41.4 falls per 1,000 person-months. The majority of falls resulted in no injury or in minor injury only. Potential risk factors investigated included sociodemographic variables, physical activity, alcohol consumption, acute and chronic health problems, dizziness, mobility, and medications. Multivariate analyses showed that the following factors were statistically significantly associated with an increased rate of falls: dizziness (incidence rate ratio (IRR) = 2.0), frequent physical activity (IRR = 2.0), having days on which activities were limited because of a health problem (IRR = 1.8), having trouble walking 400 m (IRR = 1.6), and having trouble bending down (IRR = 1.4). Factors which were protective included diversity of physical activities (IRR = 0.6), daily alcohol consumption (IRR = 0.5), having days spent in bed because of a health problem (IRR = 0.5), and taking heart medication (IRR = 0.6). Risk factors for injurious falls were similar.
In a recent study of fall prevention in 301 community-living older persons (the Yale FICSIT Trial, 1990–1993), participants in the murtifactorial targeted intervention (Tl) group experienced significantly fewer falls than participants in the social visit (SV) control group. In the present paper, the authors explore the relation between changes in the studied risk factors and the occurrence of falling. In comparison with SV participants, Tl participants showed significantly greater improvements in postural blood pressure change ( p = 0.01), step length ( p = 0.004), use of ≥4 medications ( p = 0.003), and unsafe tub and toilet transfers ( p = 0.05), while change in balance was of borderline significance ( p = 0.08). Reduction in the occurrence of falling, in turn, was at least marginally associated with improvements in balance, postural blood pressure change, step length, lower extremity strength/range of motion, and transfers. When participants were divided into tertiles based on a composite risk factor change score, a significantly higher percentage of Tl participants (42%) than SV participants (22%) were in the greatest risk factor reduction tertile. Among Tl participants, there was a progressively lower fall rate per person per year in the tertiles with the least, intermediate, and greatest risk reduction (0.832, 0.624, and 0.260), respectively. A similar but weaker relation between risk factor reduction and fall rate was seen in the SV group. When compared within tertiles, essentially adjusting for the amount of risk factor reduction, the fall rates among Tl and SV participants in the greatest risk factor reduction tertile were identical (0.260 falls per person per year), and the rates in the least reduction tertile were similar (0.832 vs. 1.040 falls per person per year); this suggests that risk factor reduction at least partially mediated the treatment effect. These results support the feasibility of implementing and analyzing the effectiveness of a multiple risk factor reduction strategy in the aged. Am J Epidemiol 1996; 144: 389–99.
The objective of this cross-sectional study was to compare scores on the Balance Scale with laboratory measures of postural sway and other clinical measures of balance and mobility. Thirty-one elderly subjects were assessed on the clinical measures and the laboratory tests of postural sway while standing still and in response to pseudorandom movements of the platform. The average correlation between the Balance Scale and the spontaneous sway measures was -.55. It was slightly lower (r = -.38) for the same parameters measured during the pseudorandom tests. There were high correlations between the Balance Scale and the Balance Sub-Scale developed by Tinetti (r = .91), Barthel Mobility sub-scale (r = .67), and timed "Up and Go" (r = -.76). The Balance Scale was the most efficient measure (effect size > 1) to statistically discriminate between subjects according to their use of each type of mobility aide (walker, cane, no aids). These data contribute to existing information on the performance of the Balance Scale and supports the validity of the Balance Scale in this geriatric population.
This study assessed the validity of the Balance Scale by examining: how Scale scores related to clinical judgements and self-perceptions of balance, laboratory measures of postural sway and external criteria reflecting balancing ability; if scores could predict falls in the elderly; and how they related to motor and functional performance in stroke patients. Elderly residents (N = 113) were assessed for functional performance and balance regularly over a nine-month period. Occurrence of falls was monitored for a year. Acute stroke patients (N = 70) were periodically rated for functional independence, motor performance and balance for over three months. Thirty-one elderly subjects were assessed by clinical and laboratory indicators reflecting balancing ability. The Scale correlated moderately with caregiver ratings, self-ratings and laboratory measures of sway. Differences in mean Scale scores were consistent with the use of mobility aids by elderly residents and differentiated stroke patients by location of follow-up. Balance scores predicted the occurrence of multiple falls among elderly residents and were strongly correlated with functional and motor performance in stroke patients.
Reproduced with permission of the Canadian Public Health Association.
Twenty hip fracture patients aged 50-64 years were compared with healthy, age- and sex-matched controls concerning balance capacity in standing and in walking. As a whole, the hip fracture patients had many concomitant diseases and low functional capacity. The patients studied did not differ from their controls as regards reported vision, hearing, and other characteristics. However, the patients deemed their balance to be worse and had a lower maximal walking speed than the controls. The patients also showed, in many aspects, more postural sway (i.e., lower balance capacity) on a computerized force platform especially when blindfolded. Patients with cervical fractures had less postural sway and smaller differences compared with their controls than when compared with the total group. About 2 years after the accident, hip fracture patients still perceived their balance to be more impaired, and showed more postural sway than the healthy controls. These factors may force us to emphasize more balance training after and, preferably, before the fracture.
The relatively large mass of the upper body and its elevated position in relation to the area of support during standing accentuate the importance of an accurate control of trunk movements for the maintenance of equilibrium. This fact has often been emphasized but never studied in detail. In this thesis the kinematics and motor patterns of simple voluntary trunk movements are investigated during standing. The analysis integrates neurophysiology and biomechanics using electromyographic (EMG) and optoelectronic techniques. Both the voluntary (primary movement) and the involuntary (associated postural adjustment) components of the movement are considered. The results demonstrate how the central nervous system (CNS) in its control of equilibrium utilizes biomechanical principles such as mechanical leverage of the different muscles and the interaction of active (muscle force) and passive forces (e.g. gravity and forces in stretched ligaments and/or muscles). Both primary and associated movements were found to be controlled by task specific and flexible muscle synergies which adapt to the mechanical demands of the situation. These task specific synergies were related to the amplitude, velocity and direction of the movement. Slow movements were often initiated through the action of gravity after a decrease or cessation of activity in postural muscles. Fast movements, however, were always initiated by a marked burst of activity in the agonist muscles. Significant relationships were observed between kinematical parameters (amplitude, duration and velocity) of fast trunk movements and temporal aspects of the EMG pattern. Multiple regression analysis indicated that the time to onset of muscle activity braking the ongoing trunk movement contained more information regarding the amplitude of the movement than did the duration of the initiating burst of activity in the prime mover. This supports the view that the initiating agonist burst is preprogrammed, whereas the braking antagonist burst may be influenced by peripheral feedback such as from muscle stretch receptors. In the early phase of a fast trunk flexion an unexpected flexion of the knees was observed. It is suggested that this knee flexion is a fast postural adjustment passively initiated as a mechanical consequence of the activation of muscles controlling the primary movement. This mechanism, which for anatomical reasons cannot act during an extension of the trunk, simplifies the feed-forward control of equilibrium during voluntary trunk flexion movements. For fast trunk extension movements a preactivation of ankle muscles occurred which resulted in a delay in the onset of the prime mover muscles when measured during a simple reaction time task.(ABSTRACT TRUNCATED AT 400 WORDS)
A randomized controlled trial was carried out to test the effectiveness of a screening programme carried out by nurses for elderly people aged 75 years and over in a general practice. A total of 151 people were randomly allocated to the test group and 145 to the control group. The test group received a home visit from a nurse at which an assessment lasting 45 minutes was made of: activities of daily living, social functioning, sensory functions, mental and emotional problems, current medical problems, blood pressure, urinalysis, haemoglobin level and compliance with medication. Both groups completed a selection of items from four health indices before and 20 months after the intervention. At follow up, the test group scored significantly better than the control group on a morale scale. However, this trial provided no evidence for better resolution of physical problems or finding activities of daily living easier in the test group compared with the control group. It is suggested that the main benefit of such a screening process is that the special attention and education provided improves adaptation to old age and awareness of the support systems available. The government has proposed an annual review of elderly people in their own home and this study suggests that the objectives of this scheme should be clarified.
A quantitative battery of tests for standing balance is needed in the assessment of functional impairments. The aims of the present study were to obtain stabilometric reference values for healthy females and males, 20-64 years of age, on a stable computerized force platform (AMTI) and to relate the balance data thus obtained to some traditional functional balance tests. Altogether, 152 subjects performed a series of tests. The test battery on the force platform comprised tests of standing with feet close together or on one leg while looking straight ahead or while blindfolded. Traditional functional balance tests were checked and various background data were collected through a questionnaire. Results of a separate test-retest reliability study of the test battery given on the force platform appeared promising, especially for the tests with eyes open. In the main study, results obtained on the force platform correlated significantly (p less than 0.001) with results of most of the functional tests. Women showed higher standing balance as compared with men. The results suggest the importance of relating the test-data not only to age but also to sex.
The significance of occupational falls is established through analysis of workers' compensation data of a major insurance company. The data covered 11% of the American privately insured workforce and exposure estimates were based on Bureau of Labor Statistics demographics. The number of incidents and the relative cost of falls were examined by age, gender, industry, climate and geographic region and empirical data are presented. These data establish the enormous cost of falls measured in terms of individual pain and suffering and in losses to industrial organizations.
Functional balance was studied in a sample of 98 women and 75 men from a population study. Tests used were one-legged stance and walking in a figure of eight. The results revealed that both static and dynamic functional balance were significantly correlated to isometric knee extensor strength, walking speed and stair-climbing capacity, while the association with activities of daily living (ADL) was modest in this sample of relatively healthy elderly persons. A sub-sample of 17 women and 10 men also performed balance tests on a force plate. Velocity of the sway path with both open and closed eyes was significantly correlated to the functional balance tests. Mean sway in the anterior-posterior direction and area tested with closed eyes were significantly correlated to the functional static balance test. There were no significant associations between the platform variables and the results in the performance tests. This study demonstrated differences between the sexes in that males were able to stand for a longer time on one leg, while they swayed more than females on the platform.
To determine the physiological factors and medications predicting injurious falls among the elderly population, the authors conducted a prospective study in a rural home-dwelling population aged 70 years or over, initially 979 persons (377 men and 602 women), from 1 January 1991 to 31 December 1992, in Northern Finland. The independent risk factors for all falling injuries, falls leading to minor injuries and ones leading to major injuries were determined. In men, the independent risk factors for all injuries were gait disturbances [odds ratio (OR) = 3.5] and the use of digitalis (OR = 2.2), those for minor injuries were gait disturbances (OR = 2.7) and the use of calcium blockers (OR = 3.0), and those for major injuries were the absence of a quadriceps reflex (OR = 4.8), gait disturbances (OR = 2.8) and the use of digitalis (OR = 2.9). In women, the corresponding independent risk factors were short step length (OR = 32.1), the use of calcium blockers (OR = 2.5) and the use of medications for improving peripheral circulation (OR = 3.7) for all injurious falls, path deviation (OR = 2.3) the use of calcium blockers (OR = 2.8) and the use of anti-inflammatory drugs (OR = 2.1) for minor injuries, and foot deformity (OR = 2.0), short step length (OR = 15.8), the use of long-acting benzodiazepines (OR = 4.0) and the use of calcium blockers (OR = 2.4) for major injuries. In order to prevent injurious falls, attention should be given to the prescription of tranquillizers, cardiovascular medications and anti-inflammatory drugs. The walking abilities of elderly people should be maintained and chronic diseases leading to peripheral neuropathy should be treated adequately.
Factors that predict functional recovery in the first few days following hip fracture and that may facilitate discharge to the home directly from the acute care setting have not been identified. This study investigated the attainment of key functional milestones by patients and discharge status from an acute care hospital following hip fracture.
Subjects were 162 community-based individuals (59 men, 103 women) aged 60 years or older who were admitted to an acute care hospital following unilateral hip fracture.
Data on personal, medical surgical, hospital course, and acute rehabilitation factors as well as functional status and placement at the time of discharge were collected. Adjusted odds ratios were calculated to determine predictors of independence in seven types of transfers and ambulation activities and discharge directly to the home.
Subjects who ambulated independently prior to fracture, stayed longer in the acute care setting, and received physical therapy on average more than once a day had improved odds of regaining independence in bed mobility, transfers, and ambulation. Subjects who regained independence and received physical therapy on average more than once a day had improved odds of discharge directly to the home from the acute care setting. Increasing age and postoperative complications reduced the odds of discharge directly home.
A substantial proportion of patients with hip fracture achieve independence in bed mobility and transfers and in ambulation with a walker during the early postoperative phase, although few progress to a higher level during a short-term stay in the acute care setting. Frequency of physical therapy, among other factors, appears to improve the odds of regaining functional independence and discharge directly to the home from the acute care setting.
The aim of this study was to evaluate the type and frequency of falls presenting to an inner city casualty department, and to identify modifiable risk factors in these patients.
A prospective descriptive study evaluated those over 65 years presenting to an inner city casualty department with falls. Over a 4-week recruitment period, all consenting subjects completed a semi-structured questionnaire regarding their falls and cognitive status. Those with unexplained (UF) or recurrent falls (RF) underwent a more detailed assessment: history and examination, gait and balance assessment, visual acuity measurement and neurocardiovascular investigations (including orthostatic blood pressure, carotid sinus massage and head-up tilt testing).
Of 200 patients with falls, 188 were interviewed; 29% could recall a reason for falling (accidental) and 30% had UF or RF. A cohort of 26 cognitively normal patients with UF and RF was fully investigated. In 23/26 patients risk factors for falls were found (median: three risk factors). These included: culprit medication (10), gait abnormalities (9) and carotid sinus hypersensitivity (19).
Falls are a common presenting complaint yet a fall is readily explained in less than one-third of cases. Investigation of RF and UF has a high yield for possibly modifiable cardiac and non-cardiac risk factors. Targeted multi-disciplinary rapid assessment of patients attending the Accident and Emergency Department because of a fall might reduce the number of hospital admissions.
The objective of this retrospective case-control study was to develop a model for predicting the likelihood of falls among community-dwelling older adults.
Forty-four community-dwelling adults (> or = 65 years of age) with and without a history of falls participated.
Subjects completed a health status questionnaire and underwent a clinical evaluation of balance and mobility function. Variables that differed between fallers and nonfallers were identified, using t tests and cross tabulation with chi-square tests. A forward stepwise regression analysis was carried out to identify a combination of variables that effectively predicted fall status.
Five variables were found to be associated with fall history. These variables were analyzed using logistic regression. The final model combined the score on the Berg Balance Scale with a self-reported history of imbalance to predict fall risk. Sensitivity was 91%, and specificity was 82%.
A simple predictive model based on two risk factors can be used by physical therapists to quantify fall risk in community-dwelling older adults. Identification of patients with a high fall risk can lead to an appropriate referral into a fall prevention program. In addition, fall risk can be used to calculate change resulting from intervention.
We investigated, by studying medical records, background factors and consequences of accidental falls of patients 65-74 years who attended the Department of Orthopedics' emergency clinic in Lund. We also assessed possible prevention measures. Fractures occurred in three quarters of the registered falls. Women were more prone to sustain fractures than men. Forearm fractures were commonest among women while hip fractures were commonest among men. One third of the patients were admitted to an orthopedic ward because of the fall. The patients who were less healthy had sustained fractures oftener and also needed more hospital care. Information regarding risk factors for falls and fractures were often missing in the patients' medical records. Impaired walking and balance, and medication increased the risk of falls. Such patients constitute a high risk group for future falls and fractures. A newly developed instrument is suggested as a routine in the emergency department to increase the awareness of risk factors for falls in the elderly. Satisfactory documentation is a prerequisite for further treatment and referrals to prevent falls and fractures.
The "get-up and go test" requires patients to stand up from a chair, walk a short distance, turn around, return, and sit down again. This test was conducted in 40 elderly patients with a range of balance function. Tests were recorded on video tapes, which were viewed by groups of observers from different medical backgrounds. Balance function was scored on a five-point scale. The same patients underwent laboratory tests of gait and balance. There was agreement among observers on the subjective scoring of the clinical test, and good correlation with laboratory tests. The get-up and go test proved to be a satisfactory clinical measure of balance in elderly people.
Preface
The Standards for Tests and Measurements in Physical Therapy Practice is a cohesive and well-organized document, complete with operational definitions and primer. During a first reading, one might readily conclude that the entire work is an academic treatise, esoteric in nature and dedicated to a select handful of clinicians with the intellectual capacity and interest to glean meaning from its organization. These Standards, however, represent far more than can be processed by a cursory glance or a preoccupied mind.
As defined by the Board of Directors of the American Physical Therapy Association (November 1984), a standard is an approved, binding, general statement of requirement used to judge quality of action or activity. As such, standards are accessible to the lay and health professional public for their scrutiny and criticism.
A study was made of 150 persons age 60 or older in Chittenden County, Vermont who were treated in an emergency department for injuries from falls, and compared them with 150 elderly neighbors not known to have such injuries. About 19 out of every 1000 elderly persons in the county are treated for falls annually but at least a third of persons in this age range have falls each year, usually not requiring treatment. A third of the treated falls were precipitated by an acute health problem, usually an exacerbation of a more chronic condition, and an additional 8% involved impairment attributable to alcohol, commonly by a person with a history of frequent, heavy drinking. Problems with canes, walkers or wheelchairs appeared to contribute to several falls among impaired persons. Persons with falls because of acute impairment had chronic limitations of mobility, vision or sensorium significantly more often than did persons with other falls or with no falls. Over half of the falls not attributable to acute impairment were caused by slippery or uneven ground. The data do not support the hypothesis that falls of the elderly commonly occur because of fractures of hips or vertebrae, but they do suggest that brittleness of bone, small muscle mass or both are substantial contributors to fractures in the elderly once the fall has been initiated. The nature of the surface struck is less important, but not entirely irrelevent, in determining the severity of injury to persons in this age range. Once injury occurred appropriate first aid was rarely provided and the injured commonly delayed for six hours or longer before seeking care and used methods of transportation to the hospital that were not conducive to limiting exacerbation of the injury. Forty-four per cent of the injured were hospitalized and, of these, 22% died within a year after injury, usually within 3 months. However, the fall injury was only rarely listed on the death certificate as an associated cause of death or significant other condition although it probably should have been listed in most cases.
The purpose of this study was to investigate the frequency, intensity and causes of sudden movements occurring at work. Another aim was to find out whether the frequency and intensity of sudden movements show a correlation with self-assessed risk of accident. Eighteen workers in the forest industry, representing low, moderate and high self-assessed accident risk categories, were selected for the study. Occurrence of sudden trunk movement was assessed by a new method based on trunk acceleration measurement. A total of 297 sudden movements were registered. The most common causes of the sudden movements were jerking and climbing, and only two sudden movements were caused by slips. We found a correlation between self-assessed accident risk and occurrence of sudden movements at work. The present assessment method did not discriminate between different kinds of sudden movements. Methods to detect sudden movements should be further developed.
The aim of the study was to develop a method for the detection and recording of sudden movements caused by a person's effort to regain balance during slipping and tripping. The method is based on the assessment of the horizontal acceleration of the trunk. A portable device was developed for recording sudden movements at work sites. The device was tested in laboratory conditions with 20 test persons. The experiments showed that the device is capable of detecting slips and even slight losses of balance which do not lead to actual falls. The acceleration levels of the trunk increased significantly in slipping incidents compared to normal walking, both in antero-posterior and medial-lateral direction.
The ability to balance is closely related to functional status and safety. It is of particular concern in the elderly as balance may be impaired due to disease or aging. The primary objective of this paper is to review existing laboratory and clinical measures of balance. To facilitate this review, the dimensions of balance and the properties of good measurement are described. Situations requiring balance can be divided into three general classifications: maintenance of a position, postural adjustment to voluntary movements, and reactions to external stresses. This complex motor skill may be viewed from a biomechanical, neurophysiological, or a functional perspective. In the laboratory, investigators have measured sway patterns and examined strategies of regaining balance after a perturbation. Recent clinical studies have shown a trend to performance based assessment. To data there is no one universally acceptable laboratory or clinical method to measure balance. Because of its importance in functional activities, the need for a good measure of balance is evident.
This guideline is intended to assist emergency physicians and nurses in the management of people older than 65 years who present to the ED after sustaining a fall. It is not intended to be rigidly applied to every such patient. Physicians may choose to individualize therapy on the basis of unique clinical circumstances, or they may adopt a variation of these guidelines on the basis of a different interpretation of the literature concerning the issues we have addressed. It was our goal to help emergency health care providers identify the causes of falls in older people and to help their patients by providing a framework in which to implement those interventions already known to improve the function status of older persons and reduce the frequency of hospitalization and nursing home care.
A system for evaluation of motor function, balance, some sensation qualities and joint function in hemiplegic patients is described in detail. The system applies a cumulative numerical score. A series of hemiplegic patients has been followed from within one week post-stroke and throughout one year. When initially nearly flaccid hemiparalysis prevails, the motor recovery, if any occur, follows a definable course. The findings in this study substantiate the validity of ontogenetic principles as applicable to the assessment of motor behaviour in hemiplegic patients, and foocus the importance of early therapeutic measures against contractures.
A new measure of balance, functional reach, has been recently developed. Functional reach is the maximal distance one can reach forward beyond arm's length while maintaining a fixed base of support in the standing position. Reliability, criterion, and concurrent construct validity of functional reach have been established. The purpose of this study was to assess the predictive validity of functional reach in identifying elderly subjects at risk for recurrent falls. Two hundred and seventeen elderly, community-dwelling male veterans (aged 70-104) underwent baseline screening and were followed for 6 months to monitor falls. Subjects with two or more falls during the 6-month follow-up were classified as recurrent fallers. Logistic regression reveals that if individuals were unable to reach, the adjusted odds ratio (OR) of having two falls was 8.07 (2.8-23.71); if their reach was less than or equal to 6 inches the OR was 4.02 (1.84-8.77); and if reach was greater than 6 inches but less than 10 inches the OR was 2.00 (1.35-2.98). The association between functional reach and recurrent falls was not confounded by age, depression, or cognition. We conclude that functional reach is a simple and easy-to-use clinical measure that has predictive validity in identifying recurrent falls.
We developed the Falls Efficacy Scale (FES), an instrument to measure fear of falling, based on the operational definition of this fear as "low perceived self-efficacy at avoiding falls during essential, nonhazardous activities of daily living." The reliability and validity of the FES were assessed in two samples of community-living elderly persons. The FES showed good test-retest reliability (Pearson's correlation 0.71). Subjects who reported avoiding activities because of fear of falling had higher FES scores, representing lower self-efficacy or confidence, than subjects not reporting fear of falling. The independent predictors of FES score were usual walking pace (a measure of physical ability), anxiety, and depression. The FES appears to be a reliable and valid method for measuring fear of falling. This instrument may be useful in assessing the independent contribution of fear of falling to functional decline among elderly people.
A new clinically accessible measure of balance, functional reach (FR), is the difference between arm's length and maximal forward reach, using a fixed base of support. The purposes of this study were to (a) establish FR as a measure of the margin of stability versus the laboratory measure, center of pressure excursion (COPE); (b) test reliability and precision, and (c) determine factors that influence FR, including age and anthropometrics. We evaluated FR in 128 volunteers (age 21-87 years). FR was determined with a precise electronic device and a simple clinical apparatus (yardstick). FR correlates with COPE (Pearson r = .71) and is precise (coefficient of variation = 2.5%) and stable (intraclass correlation coefficient across days = .81). Age and height influence FR. FR is portable, inexpensive, reliable, precise, and a reasonable clinical approximator of the margin of stability. FR may be useful for detecting balance impairment, change in balance performance over time, and in the design of modified environments for impaired older persons.
This article has no abstract; the first 100 words appear below.
THE annual incidence of falls among elderly persons living in the community increases from 25 percent at 70 years of age to 35 percent after 75 years of age.¹ Fifty percent of elderly persons who fall do so repeatedly. Falls are even more common in nursing homes, where the average annual incidence of reported falls is 1600 per 1000 patients.² Women fall more often than men until the age of 75 years, after which the frequency is similar in both sexes.¹ In the statistics reported here, and in the field of geriatrics generally, "falls" excludes those that result from major . . .
Dr. Tinetti is the recipient of an academic award (K08AG00292) from the National Institute on Aging.
Source Information
From the Department of Medicine (M.E.T.) and the Department of Epidemiology and Public Health (M.S.), Yale University School of Medicine, New Haven, Conn. Address reprint requests to Dr. Tinetti at the Department of Medicine, Yale University School of Medicine, 333 Cedar St., P.O. Box 3333, New Haven, CT 06510–8056.
To study risk factors for falling, we conducted a one-year prospective investigation, using a sample of 336 persons at least 75 years of age who were living in the community. All subjects underwent detailed clinical evaluation, including standardized measures of mental status, strength, reflexes, balance, and gait; in addition, we inspected their homes for environmental hazards. Falls and their circumstances were identified during bimonthly telephone calls. During one year of follow-up, 108 subjects (32 percent) fell at least once; 24 percent of those who fell had serious injuries and 6 percent had fractures. Predisposing factors for falls were identified in linear-logistic models. The adjusted odds ratio for sedative use was 28.3; for cognitive impairment, 5.0; for disability of the lower extremities, 3.8; for palmomental reflex, 3.0; for abnormalities of balance and gait, 1.9; and for foot problems, 1.8; the lower bounds of the 95 percent confidence intervals were 1 or more for all variables. The risk of falling increased linearly with the number of risk factors, from 8 percent with none to 78 percent with four or more risk factors (P less than 0.0001). About 10 percent of the falls occurred during acute illness, 5 percent during hazardous activity, and 44 percent in the presence of environmental hazards. We conclude that falls among older persons living in the community are common and that a simple clinical assessment can identify the elderly persons who are at the greatest risk of falling.
Many people experience a decline in mobility with aging. The multiple chronic diseases and disabilities responsible for this decline also may predispose to falling. This decline is well recognized by clinicians caring for elderly patients. The Canadian Task Force on the Periodic Health Examination not only recognized the problem, but concluded that assessing physical, social, and psychologic functions as they impact on 'Progressive Incapacity with Aging' was the most important assessment for patients over age 75. Prominent among their list of potentially preventable impairments were locomotory, sensory, and cognitive functions, each of which is intricately related to mobility. The Canadian Task Force further stated that protection of abilities should be emphasized over diagnosis. They believed that establishing the optimal content of the assessment was a high research priority. The purpose of the following discussion is to address the question of content of a functional mobility assessment appropriate for elderly patients. The limitations of relying solely on either a disease-oriented or a gait analytic approach are outlined. A practical performance-oriented assessment of mobility is described that incorporates useful features of both approaches. The recommended evaluation centers on the more effective use of readily (and frequently) obtained clinical data. Although limited to a discussion of ambulation as the expected mode of mobility (necessary because of space limitations), many of the concepts apply to other modes as well (eg, wheelchair).
The present study was designed to identify prospectively the individual chronic characteristics associated with falling among elderly persons and to test the hypothesis that risk of falling increases as the number of chronic disabilities increases. Seventy-nine consecutive admissions to three intermediate care facilities were evaluated. Twenty-five of the subjects became recurrent fallers. The nine risk factors included in the fall risk index were mobility score, morale score, mental status score, distant vision, hearing, postural blood pressure, results of back examination, postadmission medications, and admission activities of daily living score. A subject's fall risk score was the number of index factors present. The proportions of recurrent fallers increased from 0 percent (0 of 30) in those with 0 to three risk factors, to 31 percent (11 of 35) in those with four to six factors, to 100 percent (14 of 14) in those with seven or more factors. Falling, at least among some elderly persons, appears to result from the accumulated effect of multiple specific disabilities. Some of these disabilities may be remediable. The mobility test, the best single predictor of recurrent falling, may be useful clinically because it is simple, recreates fall situations, and provides a dynamic, integrated assessment of mobility.
The purpose of this study of 52 acute rehabilitation patients was to describe the reliability and responsiveness of measurements of standing balance and function and to establish the relationships between the measurements over the course of rehabilitation. Standing balance was measured with a seven-level (0 through 6) ordinal scale. Three functional activities (chair to mat transfer, locomotion, and stair climbing) were measured using Functional Independence Measure (FIM) scores. Balance and FIM scores were found to be reliable (weighted kappa > .85). Balance and FIM scores increased significantly (p < .000) between initial and final assessments (mean interval = 17.5 days). All FIM scores were correlated significantly, both cross-sectionally (rs = .444 to .774) and longitudinally (rs = .279 to .616), with balance. Moreover, changes in FIM scores were correlated significantly with changes in balance (rs = .413 to .595). The results of this study support the use of the ordinal balance scale described herein in an acute rehabilitation setting.
Functional reach (FR, maximal safe standing forward reach) is a precise, reliable, clinically accessible, age-sensitive measure of balance that approximates center of pressure excursion and validly estimates physical frailty. We now test its ability to detect improvement in balance over time. Twenty-eight inpatient male veterans (age 40 to 105, mean, 67.3) undergoing physical rehabilitation and 13 nonrehabilitation controls were evaluated at baseline and every 4 weeks using FR (yardstick method), 10-foot walking time (WT), the Duke hierarchical mobility skills protocol (HMS) and a portion of the Functional Independence Measure (FIM). Their sensitivity to change was determined using the responsiveness index (RI). FR as well as the other physical performance instruments tested were found to be sensitive to change (RI for FR = 0.97, WT = 11.26, HMS = 4.63, FIM = 4.93) and therefore, appropriate measures for use in prospective clinical trials.
A questionnaire was distributed to 159 patients with cervical or trochanteric hip fractures about the cause of their accident, their health status, and various social factors. The purpose was to compare background factors in hip fracture patients with factors in subjects without hip fracture. The responses from 102 patients were compared with 102 age- and gender-matched controls. Most patients had fallen during walking or rising, and they often fell sideways. Patients had had more symptoms of diseases, were more often afraid of falling, and were less active than control subjects. Hip fracture patients, even prior to fracture, were more frail and sedentary than average. Fracture prevention training is an important consideration in elderly patients.
Falls are not a mundane and inevitable consequence of ageing, but are a serious threat to the health and the independence of many older people. There is now very good evidence that the risk of falls can be significantly lowered by careful clinical evaluation and institution of a physical retraining programme.
Each year, about 11,000 individuals are hospitalized in the County of Stockholm for the treatment of fall injuries. This includes 15 percent of the population 65 years or older. In the County of Stockholm, an intervention program has begun which targets the elderly. The long-term objective is to develop a permanent community safety program for the elderly. A pilot study will be implemented in the municipality of Sundbyberg, a suburb of Stockholm. The pilot study is being conducted in conjunction with the local public health service. The objective is to reduce the number of fall incidents among the elderly. The program involves registration of injuries, study circles concerning health issues for the elderly, the training of personnel within the health professions, and improving the physical environment in residential areas. To obtain generalizable knowledge, the program includes evaluation of outcome effects and process studies.
Every year there are thousands of pedestrians in Sweden who are injured because of slippery pavements and roadways. Using an appropriate anti-skid device may reduce the risk of slips and falls on ice and snow. Methods to describe functional problems in walking on different slippery surfaces during winter have been developed as rating scales for evaluating walking safety and walking balance and an observation method to observe posture and movements during walking. Practical tests of all 25 anti-skid devices on the market in Sweden were carried out on different slippery surfaces; gravel, sand, salt, snow and ice. The anti-skid devices were described according to the subjects' perception of walking safety, walking balance and priority for own use. The postures and movements during walking were analysed by an expert physical therapist. The wholefoot device 'studs' was perceived as the best according to walking safety and walking balance and had the highest priority for own use.
Slipping, tripping and falling accidents at work
- P Thomas
A dynamic method for assessing pedestrian slip resistance. Thesis. Helsinki: Finnish Institute of Occupational Health
- R Grönqvist
The Swedish version of the Berg Balance Scale. Sjukgymnasten [in swedish] scientific supplement
- L Lundin-Ohlsson
- J Nyberg
- K Waling
Regaining functional independence in the acute care setting following hip fracture
- A A Guccione
- T L Fagersson
- J J Andersson
The timed up and go: a test of basic functional mobility for frail elderly persons
- D Podsiadlo
- S Richardsson
Are hip fractures preventable with nutritional measures and exercise in the elderly?
- P Buchart
The functional ageing of man
- A Rundgren
Falls in the elderly: part 2, balance, strength and flexibility
- G M Gehlsen
- M H Whaley
Patient falls in stroke rehabilitation: A challenge to rehabilitation strategies
- L Nyberg
- Y Gustafsson
Standing balance in hip fracture patients
- G B Jarnlo
- K G Thorngren