PHOTO CAPTION: A patient strengthens her lower body with a side-step exercise to improve her gait and reduce the risk of falling.
Abnormal gait and impaired balance increase risk for falls and the subsequent sequelae. It becomes a vicious cycle as fear of falling leads to a more sedentary lifestyle, which leads to increased weakness and contractures, which leads to impaired balance, abnormal gait, increased fall risk, and so on.
The Centers of Disease Control and Prevention offers four main ways to reduce risk of falling. Medication review is essential, as polypharmacy increases fall risk. Taking more than four prescription medications, regardless of their class, will increase one’s risk because of side effects such as orthostatic hypotension or impaired cognitive clarity. Another way to reduce falls is to evaluate the home environment. Determine if hazards exist such as rugs, cords, clutter, poor lighting, improper shoe wear, and even long gowns or pants (since we grow shorter with age, and this can lead to tripping). Visual acuity should be checked and corrected. Look for broken or bent, old prescription or lost glasses. Finally, exercise reduces fall risk. It is imperative that strength loss and posture deficits are corrected or minimized through a customized physical therapy plan of care. Any combination of these four will help reduce falls, but exercise is the only one that research shows may stand alone. Therefore, physical therapy should be an integral part of reducing fall risk.
In our clinic, we treat geriatric fallers, as well as those with neurological diagnoses and vestibular pathology. We see patients with hematomas, purple faces and stitches who have slow to no reactive responses and thus suffer from head injuries and fractures of the wrist, shoulder, hip and vertebrae due to falling. We help such patients regain their balance and reduce their risk of falling. To achieve this, orientation to the world around them requires sensory input, central processing, and accurate motor response.
Visual, somatosensory and vestibular input are used in varying degrees depending on the environment. Through sight, we subconsciously compare ourselves to our environment, only paying attention when an inaccuracy is detected. Is that picture tilted, or am I? Horizontal and vertical surfaces are used as references and we primarily depend on vision, which is why closing our eyes or entering a movie theater or dark restaurant can be disturbing.
Somatosensory information such as pressure, light touch, and proprioception enable us to “feel” if weight is not distributed equally. The need to compensate for inadequate sensory information may lead patients to touch furniture as they pass by and is why unlevel or softer surfaces can be more hazardous.
Vestibular input is always present and gives us our sense of verticality versus tilt and perceives movement, both velocity and acceleration in multiple planes. Dimly lit, unlevel surfaces, even carpet or variable flooring, require more input from the vestibular system to maintain an upright posture. The vestibular system is also responsible for maintaining stable gaze with head and body movement so a deficit would result in blurred vision or diplopia.
Any decline or reduced sensitivity in vision such as macular degeneration, cataracts or poor acuity, in somatosensory feedback such as sensory neuropathy, or in vestibular feedback such as with age due to slower nerve conduction, will affect balance both static and dynamic.
Central processing of these three senses is accomplished by multiple areas of the brain and brainstem. This includes, but is not limited to, the cerebellum, which coordinates sensory input with higher level cortical structures such as the basal ganglia for motor control and perception areas like the prefrontal cortex to enable us to anticipate how to respond to produce an accurate motor response or reaction.
Motor Response & Strength Requirements
Accurate motor response for achieving balance requires strength and stability from the head down and the feet up. Strength and stability can be built through series of exercises and proper training.
Strength requirements for normalization of posture and gait patterns require not only adequate core strength for spinal stabilization but also functional strength at the ankles, knees and hips. Ankle plantarflexion is needed for push-off, to propel forward and to recover from forward lean or anterior limits of stability while reaching. It is crucial and we should always test calf strength. Weak ankle plantarflexion leads to shorter step length, thus more steps to get to their destination. This reduced efficiency will require increased energy expenditure for an already fatigued client. Double, progressing to single, heel raises are a simple way to improve calf strength in a functional manner as we need those muscles to be able to lift all of our body weight with every step.
Hip extension is also needed to prevent backward falls and to assist in forward propulsion, while hip flexors are important for swing and to reduce forward lean when reaching the farthest anterior limits of stability. Quad strength is needed to maintain full weight without the knee buckling during single limb stance, and hamstring strength helps prevent hyperextension at the knee and for deceleration. Ankle dorsiflexors are used to pull forward in stance and prevent tripping during the swing phase of gait. Weak dorsiflexors lead to substitution of hip hikers and hip flexors for clearance during swing and if neuropathy has led to foot drop, bracing may be required.
Abnormal muscle tone that results from central nervous system pathologies may increase risk of falling. Imagine the need to hurry to the bathroom or out of the way of an oncoming car. Spasticity is velocity-dependent and can cause a trip due to the ankle plantarflexors fighting their ability to lift forefoot or spastic quadriceps that fight knee flexion for clearance during swing. Our patients with central pathology and abnormal muscle tone should be educated in stretching exercises for life.
Reactive strategies for reducing falls begin at the ankle and are followed by a hip response then finally a step to prevent a fall. Therefore, any reduced sensory input to “feel” an altered center of gravity and subsequently make adjustments will lead to an exaggerated, slow or no response and a fall. Balance training should include variable sensory situations, such as different density support (variable foam pad densities; rocker) or altered foot placement (feet together or on a bias such as partial tandem; foot on step or inside ledge under the sink). Training should also include the challenge of reduced visual input such as closing the eyes for increasing increments or reducing the available room light. Movement of the patient’s head or arms with head turns or tilts, or reaching off their base of support can be added as a challenge.
Task-specific training must include variability. Life involves cognitive distraction, so training should add challenges like carrying items of different sizes and weights, and thinking while walking or moving. One should not have to focus their attention on each aspect of their movement or posture. A consistent downward gaze related to posture and attention to foot placement will impair one’s ability to scan their environment and anticipate obstacles or changing conditions. Restricted cervical range of motion will cause substitution by the trunk or, worse, neglect of their periphery. Absence of scanning the environment leads to being surprised instead of being able to anticipate and prepare, which can cause greater anxiety and increased fear. Again, fear of falling leads to reduced mobility, which leads to worsening strength and posture deficits and reduced endurance, spiraling with time to further restrict mobility. Restricted mobility leads to increased risk of falls and possible medical complications of decubiti, pneumonia and even death.
We must keep our clients moving safely! The more you sit, the weaker and tighter your muscles will get, the more your chance of falling increases.
Training and Measurement Technology
Fear of falling and task-specific training can both present challenges among patients who are affected by lower extremity impairment and want to recover the ability to walk. This is not uncommon among post-stroke patients in particular. Fortunately, several technologies can be used to address these challenges in the inpatient and outpatient setting.
For example, body weight support technologies can enhance a patient’s feeling of security during gait training. Such technologies safely support the patient with a body-worn harness attached to overhead supports. This harness prevents the possibility of a fall while allowing the patient to move independently over ground or over a treadmill. These technologies range from simple overhead yolks that suspend a patient over a limited area to sophisticated, remote-controlled trolleys that move along a ceiling-mounted track and offer dynamic fall support.
Electronic walkways equipped with embedded sensors can also be helpful in evaluating gait impairment and the effects of therapeutic interventions. These technologies can be used to capture objective measures of gait such as temporal, spatial, and pressure data, and use those data to establish a baseline. This allows clinicians and patients to compare objective data, recognize progress, and improve clinical decision-making.
Finally, remember that proper posture is just as important for balance as training and strengthening. Contractures of the ankle plantarflexors, hip flexors, hamstrings or pectoral muscles may each contribute to an altered center of gravity and ability to stand upright. Think Barbie feet. Reduced ankle dorsiflexion range affects not just standing posture and center of gravity placement, but also shortens step length. Incomplete knee or hip extension will reduce the ability to stand with full weight bearing over their base of support as well as affect posture and propulsion during the midstance phase of gait. Tight pecs lead to increased thoracic kyphosis, which contributes to forward head posture as the lower cervical spine is flexed and upper region is resting in hyperextension just to look forward. We can address this and be assured that even if this posture is not significantly reducible, we can slow its progress or prevent it from worsening.
In summary, it is imperative we assess deficiencies and address them to improve strength, sensory input or substitution, and posture to improve static and dynamic balance and reduce falls. Balance and gait training can be simple considering how complex and multidimensional it is. The challenge lies in how to customize a treatment plan to consider the individual client’s past medical history and underlying comorbidities while making it fun and valuable for them. I challenge you to search through your clinical toolbox of assessment and treatment techniques and find where you feel deficient. Learn as much as you can and apply it directly and functionally to your patients. We want the outcome of engaged and active clients who are safe to promote confidence and further engagement in society. RM
Nina Chitty, PT, MHS, is a clinic director at ATI Physical Therapy in Clemson, South Carolina. She primarily evaluates and treats clients with neurological or vestibular diagnoses and geriatric fallers. Chitty earned her Bachelor of Science in Biological Sciences from Clemson University, and Bachelor of Science in Physical Therapy and Master of Health Sciences from the Medical University of South Carolina. For more information, contact RehabEditor@medqor.com.