● Tandem walking with UE support, then progressed to no support. ● Single-leg stance with UE support, then progressed to no support. ● Heel walking with support, then without support. ● Toe walking with support, then without support. ● Tandem walking backward. ● Sit to stand with two hands, then one-hand support, then no UE support. ● Stair walking using a rail. The clinician should observe performance of each prescribed exercise and provide feedback and physical assist as needed before instructing the older adult to perform these at home. Safety is key when performing balance exercises in the home environment, so older adults should be instructed to stand near a wall or counter or in a corner where there are support surfaces if they should lose their balance. Strengthening exercises Strengthening exercises designed to decrease fall risk should emphasize improving lower extremity strength in major lower limb muscles in weight-bearing positions if that is safe and appropriate for the older adult. Individual assessment results for strength should guide the clinician in determining which muscle groups should be included in a strengthening program. Although strength is important to function, a fall prevention program should include other components in addition to strengthening. In the Okubo and colleague meta-analysis of step training previously mentioned, the authors found a decrease in frequency of falls, but not due to improvements in strength (Okubo et al., 2017). They, instead, attributed a decrease in falls to improvements in reactive balance and gait stability (Okubo et al., 2017). In the Otago Exercise Program (see Resources), one of the few evidence-based fall prevention programs for more frail older adults, the lower extremity muscle groups that are targeted for strengthening include knee extensors, knee flexors, hip abductors (these three groups are important for function and mobility), ankle plantar flexors, and ankle dorsiflexors (these two groups are important for maintaining balance). Adjustable ankle weights are added to strengthening exercises for the knee flexors, knee extensors and hip abductors (progressively increasing from a half pound to 20 pounds). The starting level for each exercise is determined by the amount of ankle weight that an older adult can lift to perform 8 to 10 good quality repetitions of each exercise before fatigue. Clinicians should observe performance of each exercise and assess for substitution of other muscle groups, good breathing techniques, and slow movement through the functional range of active joint movement. The CDC/STEADI fall risk assessment protocol also recognizes the importance of functional lower extremity strength in fall prevention and provides an educational handout on sit-to-stand exercise (see https://www.cdc.gov/steadi/pdf/STEADI-Brochure- ChairRiseEx-508.pdf). A recent study by Maritz found that a 5-week/twice-a-week calf muscle strengthening program for community-dwelling older adults improved balance confidence and chair stand performance, along with decreasing TUG times (Maritz & Silbernagal, 2016). These improvements translate to a decreased risk for falls. More research is needed to determine the exact type and dosage of strengthening that can truly decrease falls. Gait training If the older adult displays significant gait deviations or a significant decline in gait speed, then physical therapy may be indicated for specific interventions to address the etiologies behind major changes in functional gait. Addressing deficits in body structure and function, such as lower extremity or back pain, lower extremity muscle weakness, abnormal muscle tone, or joint contracture, should be addressed before initiating a formal walking program. General concepts to keep in mind during gait training include challenging and advancing the gait intervention by altering the surface or terrain, the distance, the
No matter what the approach or the risk factors leading to falls, strongly supported, evidenced-based components of a fall prevention intervention should include balance, strengthening exercises, gait training, correction of environmental hazards, and correction of footwear or foot problems that affect mobility (CGS, Alvin et al, 2015). Other additional interventions that fall into the scope of a primary care provider include vitamin D supplementation (one of the few single interventions that can reduce fall risk; AGS/BGS, 2015, adjusting medications, and managing postural hypotension if present. Balance training Balance training is widely accepted as important in a fall prevention intervention. Both static and dynamic balance abilities should be assessed, as described earlier, by using a mCTSIB exam for static balance in different sensory positions, and by selecting a dynamic balance assessment that matches the older adult’s physical abilities (see Table 6). The mCTSIB can be used to identify specific deficits that should be targeted in the sensory systems used for balance and in planning an intervention that uses multisensory integration, which can be helpful in fall prevention (Whitney, Marchetti, Ellis, & Otis, 2013). For example, if an older adult has impaired integration of somatosensation, balance training that challenges vision (low lighting or eyes closed) or vestibular (head turning) input can improve overall balance performance. Depending on the assessment selected, many of the dynamic balance tasks can be used also as an intervention activity. For example, when using a Dynamic Gait Index, if the older adult has difficulty with gait during head-turning activities they should be instructed to safely practice this at home or with supervision during therapy sessions. Balance training that includes perturbations has been shown to decrease fall frequency in older adults at risk for falls (Mansfield, Wong, Bryce, Knorrs, & Patterson, 2015). Perturbation-balance training is defined in the Mansfield literature review as “the intentional application of repeated postural perturbations that cause loss of balance over the course of a training program with the goal of improving whole-body reactive balance control” (Mansfield et al., 2015). They found positive effects in programs that produced perturbations by using either equipment (moving platform), or manual nudges with losses of balance while standing on unstable surfaces. Another successful approach to balance training is called step training . A meta-analysis of step training found a 52% reduction in falls using reactive and volitional step training that employ stepping tasks that are specific to functional activities required in day-to-day movement (stepping over obstacles, side-stepping to regain balance, etc.; Okubo, Schoene, & Lord, 2017). The most effective intensity and duration of these programs has yet to be determined, but in general, it is believed that longer duration is beneficial (at least 10 weeks; Nnodim & Alexander, 2005). Whatever the balance exercise strategy, it should be individualized and at a difficulty level that challenges the older adult without being unsafe. Balance is one of the three main exercise components in the Otago Exercise Program, which is described in more detail later in this section. The Otago program is one of the few fall prevention programs that has been proven to reduce falls in homebound older adults. It includes several options for both static and dynamic balance activities that are recommended to be performed at least three times per week. Examples of balance exercises included in Otago that progress in level of difficulty include: ● Knee bends while standing with upper extremity (UE) support, then progressed to no UE support. ● Backward walking with hand support, then progressed to no support. ● Walking and turning in a figure-eight pattern. ● Walking sideways. ● Heel toe (tandem) standing with UE support, then progressed to no support.
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