ambulatory gait speed for adults is 3.3 ft/s (Table 3). Working to improve gait speed to that functional velocity should be a goal for older adults who desire that level of independence in the community. The Otago Exercise Program also includes guidelines for general walking, preferably outdoors if that is safe for the individual. The program recommends walking at a normal pace, with a friend, while wearing appropriate clothing and shoes for the climate, in well-lit areas, while avoiding multitasking. It also recommends that a walking program only be initiated after a clinician determines that it is safe to do so and has evaluated the need for an assistive device for safety. More fit older adults should strive for gait speeds closer to 3.3 ft/s, for more functional distances, and with a good quality gait pattern. Several of the balance activities included in the Otago program also involve dynamic gait and can be emphasized in a gait training program and include the following: ● 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. ● Tandem walking with UE support, then progressed to no support. ● Heel walking with support, then without support. ● Toe walking with support, then without support. Correction of environmental hazards All three fall prevention guidelines that have been discussed in previous sections recommend a home hazard assessment, followed by home modifications to remove the hazards, and follow-up assessments to inspect the modifications. The CDC/ STEADI program has a detailed educational handout that addresses potential safety hazards in the home (see https://www. cdc.gov/steadi/pdf/STEADI-Brochure-CheckForSafety-508.pdf). Examples of what to look for include, scatter rugs, loose carpet, lack of handrails, exposed electrical cords, uneven floors, small pets, clutter on walkways, poor lighting, and wet surfaces. This is an important aspect of a fall prevention program and should be carried out by a clinician or caregiver if the older adult is unable to assess their own living environment for fall hazards. Correction of footwear or structural impairments of the feet Many older adults discover the need to wear shoes with a low heel height and high surface contact area to help with balance during gait. The AGS/BGS guideline supports this practice (AGS/ BGS, 2010). Proper footwear can be described as having non- slip soles (rather than socks or slippers), low heel height, high surface contact area, and a full back or collar (no sling backs or flip flops), and a wide opening to get the foot in and out of the shoe. Foot conditions that can contribute to increased fall risk include bunions, claw toes, ingrown toe nails, and foot pain. A study published in the British Medical Journal found that a multifaceted foot care program can reduce falls by as much as 36% (Vernon, 2011). Older adults should wear proper shoes, be examined for foot conditions that affect fall risk, and practice good foot care. A good foot hygiene routine should include washing and drying feet daily, applying moisturizer, cutting toenails regularly, and seeing a podiatrist if foot conditions exist. Older adults with diabetes also should be aware of sensory deficits that could lead to the need for foot orthoses, painful neuropathy, foot ulcers, or even amputation if regular medical attention is ignored (Migliarese, 2017). physical therapists on fall risk identification and fall prevention, the Academy of Geriatric Physical Therapy developed a CGS for community-dwelling older adults. This guideline examined five existing practice guides that were broad in scope, geared toward community-based older adults, and not diagnosis specific. They developed a clinically useful summary of recommendations for physical therapists based on three of the guidelines that they
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 speed, the elevation, attention demands, postural transitions between different surfaces, dual-tasking demands, and amount of support. Once any existing etiologies are addressed and the activity of gait is safe for longer distances indoors or outdoors, the older adult can begin walking for longer distances and at faster speeds. Remember that the functional community Guidelines for interventions by living environment When designing interventions for older adults who are at risk for falls, physical therapists are called on to employ evidence-based practices to achieve effective results. Evidence-based medicine has been defined as “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients” (Sackett, Rosenberg, Gray, Haynes, & Richardson, 1996). In order to provide recommendations to
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