As discussed in my last blog post, fall prevention is important to address in older adults, but even more so for individuals who have progressive diseases (diseases which get more severe over time). Multiple Sclerosis is an example of a neurological disease for which fall prevention is critical.
I had the pleasure of working with Vicky, a 60 year old female who had a history of relapsing remitting multiple sclerosis, last Spring. Overall, the progression of Mary’s disease had been slow over the past 15 years until a recent fall down the stairs at her home resulting in a hip fracture. Mary was admitted to inpatient rehabilitation following hip surgery in order to improve her functional status before discharging home.
In speaking with Mary and getting to know her better, I realized that anxiety about falling was a major problem for her:
1) Mary had been restricting how often she would go out of her apartment to once a week because she was afraid of falling in public. [This got my attention! When a person limits their current activities due to fear of falling, it results in deconditioning, decreased strength, and even frailty—which puts a person at higher risk for falling in the future.]
2) Feeling that a cane would label her as “disabled”, Mary refused to utilize an assistive device while walking. [This required significant PT education regarding the benefits of using an assistive device to prevent falls versus not using one and falling—which is exactly what had happened to Mary.]
3) Finally, Mary disclosed that she had a number of falls around her home recently. [Which told me that her condition was progressing and she clearly needed intensive PT intervention.]
Working with Mary involved a multi-dimensional approach to improve her daily function and independence. Firstly, I had to “coach” Mary on her current abilities (how much she could do on her own) and her current functional limitations. I had to help to build her confidence by putting her in challenging situations (ie. practicing flights of stairs, walking on gravel/grass/sand, moving out in the community) to show her how much she could do on her own. We talked at length about the negative effects of another fall—pain, decreased function, decreased independence, etc. By opening her eyes to her actual balance abilities and education about the consequences of decreased balance, I slowly introduced Mary to different potential assistive devices to help her (including cane versus forearm crutch versus walker) and we practiced using them in different environments.
In addition, I utilized standardized “Fall Assessment Measures” to determine her risk for future falls. We commonly use these in physical therapy to objectively show change in our patients over time (from initial evaluation through discharge). Even more importantly, I use these balance assessments to educate my patients about their score and the implications about their score (based on research). For example, the Berg Balance Scale involves 14 items of a person performing different standing balance positions (single limb stance, tandem stance) and functional activities (reaching forward, picking something off the floor, sit to stand). The person is rated from 0-4 on each item depending on their score. A maximum of 56 is possible with scores less than 36 indicating a 100% chance of falling within the next year and scores less than 45 at high risk for falls. Other balance measures I commonly use are: Dynamic Gait Index, Functional Gait Assessment, and the Activities-Specific Balance Confidence Scale (to name a few). You might want to look some of these up online to get more information.
Before Mary discharged from rehab, I made sure that we had evaluated her home to decrease fall hazards: removing throw rugs, decreasing clutter on the floor, placing nightlights in bedroom/bathroom, installing a grab bar and non-stick rug in the tub, and creating more space between furniture so that a clear path for walking was established. Mary also went home with a home exercise program that targeting: strengthening of her hip muscles, balance exercises with a narrow stance, and a daily outdoor walking program with her crutch. Our biggest goal for her home program: No falls for one year! :-) She is checking back in with me every month to tell me how she’s doing.