Balanced Physical Therapy

Balanced PT distributed this article to area doctors on 1/16/08

Medicare currently asks practitioners to evaluate patients aged 65 & older for risk of falls at least every 12 months.  This adds to the growing consensus that older patients should receive fall risk assessments as part of annual exams.¹Â  Prescriptions for physical therapy have been shown to reduce falls among seniors^2-4, but payors often ask that interventions beyond counseling be reserved for those patients presenting a high risk for future falls.  Prescribers can quickly and easily assess patients.

First, include a question about falls in the history.  Patients who report a fall are at higher risk for future falls.⁵  When patients report accidental falls, further questioning about how the fall occurred will help determine the optimal intervention(s).  Complaints of dizziness, confusion, etc suggest medical intervention.  Complaints of sidewalks being too uneven, normal clothes interfering with gait, etc suggest a therapy intervention.  Multifactorial fall prevention programs including medication review, therapy, and education have proven the most effective interventions6, so prescribers might often find that patients would benefit from medical interventions plus therapy.  The history of a fall in and of itself indicates a higher risk of future falls.⁵  When you deem that physical therapy could improve one of the contributing factors, no further testing is required.  However, a physical assessment for the risk of falls may help persuade a patient to act on your recommendations.

When there is no history of falls (or when you want further proof), practitioners should include a physical test assessing the risk of falls.  The Timed Up-And-Go Test (TUGT) stands as the quick and practical test with the most scientific validation, but, in the past, most physicians have received sub-optimal instructions for this test.  In the Timed Up-And-Go Test, the patient starts seated in a chair with arms.  The patient is asked to stand, walk 9 meters (10 ft) at a normal walking pace, turn around, walk back to the chair, and sit down.  This test was previously used as a measure of functional dependence, and times of 20 seconds and 30 seconds have been suggested as indicators of functional dependence.  For this reason, many authors have suggested these scores for the cut-off points for fall prevention measures.⁷  Over the past few years, experts have begun updating that advice.⁸  Payors such as Medicare use the language “high risk of falls” as the standard for prescribing therapy, and functional dependence proves to be a higher standard than high risk of falls.  When times from the TUGT have been specifically correlated with risk of falls, studies have recommended cut-off points of 10 seconds to 15 seconds.^9-14  Since 30 to 40% of community dwelling seniors older than 65 fall each year, practitioners should expect a significant percentage of their senior patients to qualify for fall prevention efforts.^15-16

When it comes to fall prevention, Balanced Physical Therapy can help you and your patients in two ways.  One, Balanced offers Balance C.A.M.P., an expert, comprehensive fall prevention program including vestibular assessment and rehabilitation.  Two, Balanced will send a physical therapist to your office to in-service you and your staff on fall risk assessment.  Balanced will do this for you as a complimentary service.   

Refer At Risk Patients to Balance C.A.M.P.
Community Ambulation & Mobility Program

When you prescribe physical therapy for fall prevention, most good therapists will provide proprioceptive rehab, strengthening, flexibility improvement, training with assistive devices, and education.  Balance C.A.M.P. provides all of this plus thorough vestibular assessment and rehabilitation.  Gaze instability, dizziness, disequilibrium, etc can contribute to risk of falls.  Balance C.A.M.P. can identify and improve these intrinsic factors as part of a more comprehensive fall prevention program.

References:

1. American Geriatrics Society, British Geriatrics Society, and American Academy of Orthopaedic Surgeons Panel on Fall Prevention. “Guideline for the prevention of fall in older persons.”J Am Geriatr Soc 2001; 49: 664-72.
2. Province MA, Hadley EC, Hornbrock MC, Lipsitz LA, Mulrow CD, Ory MG, et. al. The effects of exercise on falls in elderly patients: A pre-planned meta-analysis of the FICSIT trials. Journal of the American Medical Association 1995;273:1341-7.
3. Rubenstein LZ, Josephson KR, Robbins AS. Falls in the nursing home. Annals of Internal Medicine 1994;121:442-51.
4. Judge JO, Lindsey C, Underwood M, Winsemius D. Balance improvements in older women: effects of exercise training. Physical Therapy 1993; 73(4):254-65.
5. Ganz DA, Bao Y, Shekelle P, et al. “Will my patient fall?” JAMA. 2007; 297 (1): 77-86.
6. Chang JT, et al. Interventions for the prevention of falls in older adults: systematic review and meta-analysis of randomised clinical trials. BMJ March 20, 2004;328:680-3.
7. Fuller G. “Falls in the Elderly.” Am Fam Physician 2000; 61: 2159-68, 2173-4.
8. Roa S. “Prevention of Falls in Older Patients.” Am Fam Physician 2005; 72: 81-8, 93-4.
9. Whitney J, Lord S, Close J. “Streamlining assessment and intervention in a falls clinic using the Timed Up and Go Test and Physiological Profile Assessments.” Age and Ageing. 2005; 34 (6): 567-571.
10. Podsiadlo D, Richardson S. “The times ‘up and go’ a test of basic functional mobility for frail elderly persons.” J Am Geriatr Soc 1991; 39: 142-8.
11. Bischoff H, Stahelin H, Monsch A, et al. “Identifying a cut-off point for normal mobility: a comparison of the timed up and go test in community-dwelling and institutionalized elderly women.” Age Ageing 2003; 32: 315-20.
12. Shumway-Cook A, Brauer S, Woollacott M. “Predicting the probability of falls in community-dwelling older adults using the times up and go test.” Phys Ther 2000; 80: 896-903.
13. Rose DJ, Jones CJ, Lucchese N. “Predicting the probability of falls in community-residing older adults using the 8-foot up-and-go: a new measure of functional mobility.” J Phys Activity Aging 2002; 10: 466-75.
14. Gunter B, White N, Hayes W, et al. “Functional mobility discriminates nonfallers from one-time and frequent fallers.” J Gerontol Med Sci 2000; 55A: M672-6.
15. Campbell AJ, Borrie MJ, Spears GF. “Risk factors for falls in a community-based prospective study of people 70 years and older. J Gerontol 1989; 44: M112-7.
16. Tinetti ME, Speechley M, Ginter S. “Risk factors for falls among elderly persons living in the community.” N Engl J Med 1988; 319: 1701-7.

 

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