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Assessing Balance and Falls

Assessing Balance and Falls

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Published by: cpradheep on Feb 08, 2010
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Assessing Balance and Falls
(Accessed on : 20/02/2005, This site is no longer available now)Author:Lauren Robertson, BA, MPT2.5 contact hours
Course posted
March 31, 2003
Course expires
March 31, 2005
Course Objectives
Upon completion of this course the learner will be able to:
Describe the factors associated with falls and fall-related injuries in the elderly.
Discuss nursing and therapy interventions in the evaluation and treatment of falls.
Describe which sensory systems contribute to balance and postural control.
Describe the main components of the balance evaluation.
Describe 3 age-related changes that may adversely affect balance.
Why Learn About Balance and Falls?
As medical professionals, most of us rarely think about balance or loss of balance andprobably take it for granted in our own lives and in the lives of people we see in the medicalsetting. We may find ourselves thinking about balance when a patient falls and then often onlyin terms of filling out paperwork or deciding on the proper restraint. If pressed, most of uswould have trouble identifying the components of balance - what makes our balance goodand what happens when balance declines and leads to falls and loss of independence. Evenmore critically, what can be done to improve balance and reduce the risk for future falls.
The first section of this course will describe risk factors and the costly effect of falls in theelderly population. The second section will describe the main components of the balanceexamination and what parts of the nervous and musculoskeletal systems contribute tobalance. The third section will review common diseases and disorders that contribute tobalance deficits and outline a method for performing a balance evaluation. A case study ispresented to demonstrate the use of these evaluation techniques in the clinical setting.
Can Balance be Assessed?
It is astonishing to think that we balance the large, heavy mass of our bodies and heads ontop of two very short, almost delicate feet. In the elderly and in those with balanceimpairments due to illness or injury, the body becomes an unwieldy tower of uncontrolledlevers that seems suddenly incapable of sustaining itself in the upright position. Assessing aperson with a balance deficit can seem complicated, confusing and discouraging. We arefortunate that we are able to turn for answers to an avalanche of research done on balanceand falls in the last 20 years. Even armed with the latest information on balance research, ittakes practice and determination to integrate this information into the clinical setting.
What is Balance?
Balance is defined as the ability to maintain the body's center of mass over its base of support(Shumway-Cook, 2001). Good balance exists because multiple systems interact flawlesslyand automatically, providing accurate and exact information to our nervous systems. Weconstantly process, assess and re-assess information about the strength, force, timing andspeed of movement. Our brains receive information from sensory receptors located in theeyes, inner ears, joints, muscles and skin - all providing important information for balance.Cognitive factors such as fear of falling and dementia, medications and medical condition alsoaffect balance. Testing to determine the cause of a balance disorder requires knowledge ofeach of these systems and the ability to identify which factor or factors contribute to thebalance deficit. A proper balance evaluation systematically evaluates each of these factorsand directs the examiner to an effective and specific treatment plan.
Can Falls be Assessed?
Effective assessment of fall risk requires a wholistic approach and includes the review ofmany complex and interconnected factors. The difficulty lies in determining what factors affectbalance and contribute to falls and conversely, what factors can be addressed to reducefuture falls. Falls are the result of impairment in one or more complex and interrelatedphysiologic systems as well as environmental factors. Many studies (and common sense)have shown that as balance becomes gradually more impaired, the risk of falling increases.Advancing age and multiple impairments (and medications used to treat those impairments)increase the risk of falls. (Tinnetti, 1994)
Many factors contribute to falls and subsequent fall injury. Fall risk increases rapidly withadvancing age for persons aged >65 years. Other fall risk factors include lack of current orprevious physical activity, muscle weakness or balance problems that can contribute both tothe risk for falling and the inability to break the impact of a fall, functional limitations (e.g.,difficulty with activities of daily living such as dressing or bathing), cognitive impairment ordementia, use of psychoactive medications (e.g., tranquilizers or antidepressants), somecombinations of medications, environmental factors (e.g., tripping hazards), having fallenpreviously, having more than one chronic disease, having had a stroke, Parkinson disease ora neuromuscular disease, urinary incontinence, and visual difficulties. Less clear is the fallrisk associated with wearing shoes with thick, soft soles (e.g., jogging shoes) that can affectbalance and proprioception or become a tripping hazard by catching in carpeting. (Stevensand Olson, 2000)
Other studies site the use of more than 4 medications, poorly maintained and/or improperlyfitting wheelchairs, poor transfer techniques and suboptimal care (Ray, 1997) as importantfactors contributing to falls. Tinetti and others have postulated that "geriatric syndromes"involving intermittant episodes of falling, urinary incontinence and delirium resulting fromimpairments in multiple systems can lead to functional decline (Tinnetti, 1995).
Although the cause of falls is multi-factorial, evaluation can be simplified by placing riskfactors into two overall categories, internal and external factors. Internal risk factors includecardiovascular, neuromuscular, orthopedic, perceptual and psychiatric or cognitiveimpairments. External risk factors include medications, appliances, assistive devices,environmental hazards and level of care. Table 1 describes internal and external risk factorsfor falls and suggests possible causes.
Table 1: Risk Factors for Falls
Internal RiskFactors
Lower extremity weakness, loss ofmovement, functional decline,hypotension, CVA, Parkinson's, stroke,neurological disorders, seizure disorder,syncope, unsteady gait, chronic/acuteconditions
Joint pain, arthritis, hip fracture, limbamputation, osteoporosis, foot disabilities
Impaired hearing, impaired vision,somatosensory deficits/neuropathies,dizziness/vertigo
Psychiatric orcognitive
Delerium, cognitive decline, dementia,Alzheimer's disease, depression,wandering, confusion/disorientation, fearof falling
Medication sideeffects
Hypotension, muscle rigidity, impairedbalance, extrapyramidal symptoms(tremors, uncontrolled movements),decreased alertness
External RiskFactors
Psychotropics, cardiovascular meds,diuretics, antidepressants,antianxiety/hypnotics, ETOH/drug abuse
Appliances anddevices
Pacemaker, cane/walker/crutch,restraints, poor fitting wheelchair
Glare, poor lighting, slippery floors,uneven surfaces, patterned carpets,foreign objects, recent move into or withina facility, proximity to aggressive patients,time of day, time since meal, type ofactivity, walking in a crowded area,reaching, bladder/bowel urgency

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