An OP&P Approach to Fall Prevention

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By Dennis Janisse, CPed
graphic of figure stopping falling dominoes

The prevention of falls among the elderly population has become a major initiative for healthcare providers and insurers in the United States and many countries around the world. This issue concerns the OP&P community as well, since older adults comprise a large portion of our collective patient population. And that population is only growing: According to a July 2015 Forbes article, 10,000 seniors are enrolling in Medicare daily.1 Interestingly, the same article states that while the number of total U.S. jobs has increased by 6 percent over the last decade, the number of home health jobs has grown by 60 percent, as more aging adults require that care. As one could imagine, problems related to unintentional falls are a common reason many of those seniors require home healthcare.

The increased attention focused on fall prevention is more than justified. The Centers for Disease Control and Prevention (CDC) estimates that one in four Americans age 65 or older will fall each year; other researchers have pegged the number as high as 30-60 percent.2 Greater than 95 percent of all hip fractures result from a fall.3 Falls are also the most frequent cause of traumatic brain injury.4 Falls among older adults often lead to premature nursing home admissions. A senior falls every 11 seconds in our country, and every nine minutes an older adult dies as a result of fall-related complications.5 Unintentional falls are the leading cause of fatal injury and the most common cause of nonfatal, trauma-related hospital admissions among older adults. The CDC reports that the annual number of deaths caused by falls in the United States is almost equal to those caused by motor vehicle accidents (30,208 versus 33,804).6 Given statistics like these, do we not, as allied healthcare providers, owe it to our patients to do all we can to help them avoid such catastrophes?

Unintentional injuries are the fifth leading cause of death among the U.S. aged population (after cardiovascular disease, cancer, stroke, and pulmonary disorders) and fully two-thirds of those deaths are fall-related.2 In the United States, 75 percent of fall-related deaths occur in people age 65 or older although this age demographic constitutes only 13 percent of the population.2 Of those fall victims admitted to a hospital for treatment for their fall-related injuries, about half will die within one year.2 What's more, the fear of falling can cause anxiety, decrease self-confidence, and significantly impact quality of life as the individual becomes less active and stays closer to home-factors that can actually increase the risk of falling.

The CDC has identified several risk factors for falling, and tries to educate seniors and healthcare providers about them. They include things such as lower-limb and core muscle weakness, difficulties with walking, balance and proprioception issues, impaired vision, use of certain medications that can cause dizziness or affect balance, and household and environmental dangers like throw rugs, clutter, lack of handrails, or broken steps. They also point out that foot pain and inappropriate footwear can be contributors.7 Environmental hazards are the leading cause of falls (25-45 percent, depending on the study).8 Gait disturbances, postural hypotension, vertigo, confusion, and syncope can also cause falls.

Of course, falls are often caused by a combination of these risk factors, and the more risk factors a person has, the greater his or her chances of falling. Allied healthcare providers can help lessen a person's risk by reducing the aforementioned contributing factors to accidental falls. Specifically, as OP&P professionals, we can help alleviate our patients' foot pain and ensure they wear proper footwear. We can also help improve their balance.

Fall prevention, like so much of the treatment OP&P professionals provide, is best approached using a multidisciplinary team. Common prevention techniques with other members of an interdisciplinary team include physical therapy for improving strength and balance, treating poor vision, and assessing and perhaps adjusting medications. Patients' homes can also be assessed for fall risk factors and problems can be remedied-for example, installing handrails in the bathtub and next to the toilet, organizing and eliminating clutter, making sure there are handrails on both sides of the stairs, wrangling electrical cords, removing loose rugs, and ensuring that the home is adequately lit.2 German researchers recently noted a disturbing ambivalence, however, within the target population concerning fall risk and the importance of fall prevention.9 They stated that the willingness to engage in preventive measures depends on several personal factors, the quality of information provided, guidance and decision making, and social support. This reinforces the need for us, as trusted OP&P professionals and valuable patient advocates, to get involved in helping to prevent falls amongst our patients, neighbors, and even elderly family members.

How can we help? There are ongoing debates in the OP&P and podiatric communities regarding the effects AFO usage may have on balance and proprioception.10,11 Within the podiatry world, the objectivity of debate (in this author's opinion) is somewhat tainted by the fact that both the primary advocate and his leading critic have designed and manufactured competing braces.

In the OP&P realm, however, the questions trend more toward, "Do the potential benefits outweigh the risks?" There is little question that AFOs do affect balance. There is actually quite a bit of published research on this topic. The problem is that sometimes the effect is positive, while in other cases it is demonstrably detrimental. Many different styles of foot and ankle braces can and do improve static balance and postural control, but many of those same AFOs can potentially compromise dynamic balance and actually cause a fall.

For this reason, let us instead focus on treatment modalities with little inherent risk and time-tested positive impact on balance, gait mechanics, and proprioception. Pedorthic modalities including appropriate footwear, shoe modifications, and custom total contact foot orthoses can be used to improve postural sway and proprioception.

The first step is evaluating the patient's current footwear. Check the fit. Is the construction appropriate? Is it too heavy for the patient? Is there a loss of support or cushioning? Many times, patients with sensory neuropathy will fit their shoes too tightly as they perceive better environmental feedback this way. However, cramping the toes and foot can actually cause the patient to stumble just as easily as wearing a shoe that is too large.

A custom foot orthosis constructed of a semirigid material like ethylene-vinyl acetate (EVA), cork composite, and/or polyethylene foam can be helpful for improving balance. The orthosis needs to be a total contact design when used for this purpose, though. Thus, so-called functional rigid foot orthoses are contraindicated due to the reduction of intimate interface that is affected by the multitude of cast modifications performed to the positive foot model. A total contact design essentially brings the ground up to the foot, allowing the entire plantar surface of the foot to be in contact with the walking surface, thereby improving balance and proprioception.

Shoe sole modifications can also be helpful.2 One must be careful when considering shoe modifications, however. Rocker soles, one of the most commonly used modifications for treating foot and ankle pathologies, may be contraindicated for individuals with balance and postural control issues. Outflares, buttresses, and relast modifications are all excellent tools for providing a wider, more stable base of support for these patients. Just remember to keep the weight of the shoe reasonable.

There is one more thing that OP&P professionals can do to assist in the fight against unintentional falls. That is, of course, education. Get involved. Participate in community health fairs; offer to do in-services for senior citizen or retirement groups, local physicians, and physical therapists; and submit articles for publication in local newspapers. Take the time to discuss this vitally important topic with each and every one of your at-risk patients. They and their families will thank you.

Dennis Janisse, CPed, is president and CEO of National Pedorthic Services, headquartered in Milwaukee. He is also a clinical assistant professor in the Department of Physical Medicine and Rehabilitation at the Medical College of Wisconsin and a consultant for DJO Global, Vista, California.

References

  1. Diamond, D. 2015. 10,000 people are now enrolling in Medicare - every day, July. www.forbes.com/sites/dandiamond/2015/07/13/aging-in-america-10000-people-enroll-in-medicare-every-day/#4d9ea4c35e07 (accessed October 3, 2016)
  2. Rubenstein, L. Z. 2006. Falls in older people: Epidemiology, risk factors and strategies for prevention. Age and Aging 35 (suppl. 2):ii37-41.
  3. Hayes, W. C., E. R. Myers, J. N. Morris, T. N. Gerhart, H. S. Yett, and L. A. Lipsitz. 1993. Impact near the hip dominates fracture risk in elderly nursing home residents who fall. Calcified Tissue International 52 (3):192-8.
  4. Jager, T. E, H. W. Weiss, J. H. Coben, and P. E. Pepe. 2000. Traumatic brain injuries evaluated in U.S. emergency departments, 1992-1994. Academic Emergency Medicine 7 (2):134-40.
  5. National Council on Aging. Falls prevention facts. www.ncoa.org/news/resources-for-reporters/get-the-facts/falls-prevention-facts (accessed October 3, 2016)
  6. Centers for Disease Control and Prevention. Accidents or unintentional injuries. www.cdc.gov/nchs/fastats/accidental-injury.htm (accessed October 3, 2016)
  7. Centers for Disease Control and Prevention. Important facts about falls. www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html (accessed October 3, 2016)
  8. Rubenstein, L. Z., and K. R. Josephson. The epidemiology of falls and syncope. 2002. Clinics in Geriatric Medicine 2002;18 (2):141-58.
  9. Luhmann, D., S. Schramm, M. Bremer, K. Balzer, and H. Raspe. 2012. Falls prevention for the elderly. GMS Health Technology Assessment 8:1861-3.
  10. Groner, C. 2012. Can AFOs help prevent falls? Lower Extremity Review, August. lermagazine.com/cover_story/can-afos-help-prevent-falls (accessed October 3, 2016).
  11. Richie, R. 2012. The truth about AFOs and fall prevention. Podiatry Today, February. www.podiatrytoday.com/blogged/truth-about-afos-and-fall-prevention (accessed October 3, 2016)