Managing Fall Risk

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By Maria St. Louis-Sanchez

The effects of a fall for patients with lower-limb amputations can be traumatic.
Falls can delay their physical recovery, create financial hardship,
and trigger a fear that limits their progress.

Unfortunately, most people with lower-limb amputations will eventually experience a fall.

"Falling is more common than we'd like to admit," says Gary Wall, MSPO, CPO, Del Bianco Prosthetics and Orthotics, Raleigh, North Carolina. "I think part of that is that we're not asking patients if they have fallen as much as we should."

Acknowledging the risk is key for medical providers working with patients, the experts say, and providers need to work together for a solution that addresses the physical, mental, and device selection elements of the problem. 

The Impact of Falls

While the experts agree that falls are common for patients with lower-limb amputations, it's hard to determine exactly how prevalent falls are.

"We lack the methods to collect that data in a repeatable and meaningful way using an approach that is relevant and understandable to people with lower-limb amputation," says Andrew Sawers, PhD, CPO, assistant professor in the Department of Kinesiology at the University of Illinois at Chicago.

Most of the studies ask respondents to remember previous falls, which could lead to accuracy issues, he says.

"You can imagine there being issues with how accurately the falls are recalled but also the exact number and circumstances of those falls."

However, even with the limitations of the data, most studies show that about 50 percent of people with lower-limb amputations will experience at least one fall per year, Sawers says.

About one-third of those with lower-limb amputations will experience two or more falls in a year, says Matthew Major, PhD, assistant professor of physical medicine and rehabilitation and biomedical engineering at Northwestern University.

Studies show that falls have the greatest chance of injuring the patient during the surgical recovery stage, with about 61 percent of those falls causing injuries.1 When a fall happens at that stage, the effect can be catastrophic to the patient, the experts say, including causing more injury and delaying prosthetic fitting.

"For the new amputee who is still healing, we see the larger physical ramifications," Wall says. "They can land on their residual limb and open up their surgical scars leading to much longer healing times."

Falls are common because it takes time for patients to become used to living with their changed circumstances.

"Many times, they are used to having a leg and they step out of bed and it's not there," says Darren Stoop, DPT, PT, physical therapist at the Hanger Clinic in Omaha, Nebraska.

Even after the post-surgical period, patients are still at an increased fall risk because it takes time for them to learn to trust their prosthesis. "They have this mindset that once they get their prosthesis that things will immediately get better, and then they realize it's not going to be as easy as they thought," Stoop says. "It's intimidating, and their fear is incredibly high; they have to trust a device that is not a part of them."

Falls can have a big impact financially as well. According to a 2017 Rochester Epidemiology Project study, patients who required a visit to the emergency room had a median six-month post-fall cost of $18,091, and those who required hospitalization had a cost of $25,652.2

While the physical and financial impacts are big, it is often the psychological impact from falls that keep a patient from progressing, the experts say.

"It can be a huge psychological impact, especially for someone who has a high fear of falling," Stoop says. "If their main goal in life was to get through the day without falling, and they do fall, it can take a long time to recover mentally from that fall."

This fear of falling can keep patients from walking as much as they are able, trying new techniques, or going to new places, and, as a result, slow their overall recovery.

"Fear of falling definitely plays a huge role in their recovery and is probably the biggest limiting factor," Wall says. "That tends to be the biggest hurdle that we or physical therapists have to coach them through."

Working to Prevent Falls

There's no magic solution to preventing every fall, Major says.

Instead, the best way to lower the fall risk for patients is by working with other medical professionals to address all sides of the risk.

"A collaborative approach is crucial," Wall says. "We can't do it all; we need a team approach to prevent falls."

"Fall risk has to be addressed holistically," Major adds. "There's a physical component to it but also a psychological component."

Some suggestions for addressing the physical and psychological aspects and the role of the prosthetic device include:

  • Muscle training: Strengthening certain muscles and the body's core can help patients achieve better balance and thus help prevent falls.3
  • Cognitive behavioral therapy: This kind of therapy can help patients understand how their fear of falling leads them to avoid certain activities, Major says. It's designed to help them increase their confidence.
  • Prosthesis selection: A well-fitted, comfortable device is key for patients to be able to walk. Studies have also shown that microprocessor knees (MPKs), especially for K2 ambulators, can help prevent falls.4

The high cost of this technology however has made it prohibitive to some patients, Stoop says.

"[MPKs] are not always available to the people who need them most," Stoop says. "It's too bad because they are definitely a game-changer. If [patients] are walking and stub their toe, if that knee has stumble recovery, they have a chance to recover. If they stub their toe on a mechanical knee and it doesn't swing through, they will likely go down."

To help their patients qualify for this technology, Stoop and Wall say that documentation is key. This means tracking patients' progress from the very beginning and really knowing patients, their current lifestyles, and their goals.

"You have to be thorough with your documentation," Wall says. "If you put the time in during your initial evaluation, you'll face less denials and audits, which will enable the patient to acquire appropriate technology in a timely manner."

Being thorough means giving a specific history of the patient instead of a generic one, Wall says. Practitioners should include their patient's vocational needs, the kind of recreational activities he or she does and aspirations for participation in any other kind of activities in the future.

"If you paint a large and clear enough picture, coach them along through the rehabilitation process, and get that minimum K3 score on your AMPnoPRO, you have a good chance of being approved for items that have proven to reduce fall reductions, such as MPKs," he says.

To get to that score, some patients may need extensive physical therapy before they are ready for their devices.

"We've partnered with hospitals with large physical therapy departments and before [patients] even have their staples out, they are going to therapy five days a week, sometimes twice a day," Wall says. "They are becoming stronger and learning how to safely ambulate without a prosthesis. By the time they get to us, they are ready."

If patients don't initially qualify for MPKs, Stoop says his goal is always to get his K2 patients to the point where they will be approved. This means more therapy and doing so well on their current knees that they are pushing the devices' capabilities.

"We can get to the point where we can point out that their current knee is not meeting their needs," he says. "They may need to walk over uneven terrain or want to change their walking speeds and those needs put them at a higher risk of falls in the knee they have."

If the patient is initially denied, he says, it can be a motivation to work even harder.

"Let's prove them wrong," he says of the mentality toward the insurance companies. "Let's show them what you can actually do." 

Training Patients How to Fall and Recover

While most patients are trained on how to prevent falls, many are never taught what to do when they actually fall. That is, how they can fall in the safest way possible to help prevent injury.

This is concerning, says Charles Noble, MSOP, who works at Hanger Clinic in Columbia, South Carolina, because most patients will eventually fall, and training could help minimize the risk of injury.

Some studies, though not focused on patients with amputations, show that fall training—particularly modified martial arts techniques—have been shown to help prevent injury.5

"Falls are going to happen, unfortunately," Noble says. "We need to equip our patients with the knowledge of how to fall properly. It needs to start early."

In a survey Noble conducted of 169 people with lower-limb amputations, 69 percent said they had never received fall training. Noble says that lack of information about falling techniques for patients with amputations could be part of the problem.

It can be difficult to teach falling strategies, Stoop says. "The dilemma is how do you train a reaction? Falling happens in a split second, it's not like it happens in slow motion. You would have to train so much that it would become a natural reaction."

Also, he says, it's difficult training to do safely since the best way to train someone to fall properly is to actually have them fall.

"Some places have overhead suspension systems," Stoop says, "so if [patients] go down, they can go down safely, but a lot of clinics don't have that luxury," he says.

Stoop does however, train patients a lot about how to get back up after a fall. "You will be amazed at the boost in confidence in knowing they can get back up," he says. "Part of the fear in falling is the fear of not getting back up."

Another type of training to help prevent falls is to have the patients purposely trip in a safe environment. Major is studying fall risks through this type of training. In his studies, the participants, wearing a harness, walk on a treadmill that can speed up and slow down quickly, causing a stumble. Over time, the patients figure out different ways to react to the tripping hazard.

"With perturbation training, such as repeated exposure to a trip disturbance, you can allow prosthesis users to explore those motor strategies responsible for successful recovery. So when a similar disturbance occurs out in the community, their body recognizes that sensation and reacts accordingly," Major says. 

Identifying Risk Before the Fall

For many patients, fall risk can increase over time. As patients age, their balance and cognitive abilities may decrease, or other comorbidities associated with age may increase their fall risk. For example, patients with diabetes could develop neuropathy in their intact limbs, making it harder to feel changes in the ground that could contribute to a fall.

Unfortunately, an increased fall risk is usually only detected after a fall. That's a backwards approach, Sawers says.

"Ideally you want to know someone's risk of falling before they fall," Sawers says. "Wait for someone to fall before determining that they are at risk for a fall is not the most ethical way to go about it."

While there is no ideal approach to determine fall risk among people with lower-limb amputations, Sawers says that at a minimum, healthcare professionals should regular administer psychometrically sound performance-based balance tests for which cutoff thresholds are available to interpret fall risk from test performance. Further, tracking common fall risk factors like muscle weakness, age, number of prescription medications, and comorbidities, as well as sense of vibration is recommended. A change in any of these factors could be a sign of increased fall risk, and may signal a need for a different device, additional physical therapy, or both, he says.

Although there is a growing body of research to help assess fall risk, this kind of testing and monitoring of prosthesis users may not be happening as it regularly as it should, Major says, and he's concerned it will take time before that improves.

"In my opinion, our healthcare system right now depends more on reactiveness," Major says. "We struggle with preventative medicine, which could help identify persons at risk of falls and improve their balance before a fall occurs. Furthermore, we can always do better with monitoring patients in the long term to account for their changing health status and risk."

"The hope at the end of the day is that we will get there," he says. "We're not there yet." 

Maria St. Louis-Sanchez can be contacted at


1.  Steinberg, N., A. Gottleib, I. Siev-Ner, and M. Plotnik. 2018. Fall incidence and associated risk factors among people with a lower limb amputation during various stages of recovery-a systematic review. Disability and Rehabilitation, doi:10.1080/09638288.2018.1449258.

2.  Mundell, B., H. M. Kremers, and S. Visscher, et al. 2017. Direct medical costs of accidental falls for adults with transfemoral amputations. Prosthetics and Orthotics International 41(6):564-70.

3.  Z. A. Schafer, J. L. Perry, Vanicek, N. 2018. A personalised exercise programme for individuals with lower limb amputation reduces falls and improves gait biomechanics: A block randomised controlled trial. Gait & Posture 63:282-69.

4.  Hasenoehrl, T., T. Schmalz, and R. Windhager, et al. 2018. Safety and function of a prototype microprocessor-controlled knee prosthesis for low active transfemoral amputees switching from a mechanic knee prosthesis: A pilot study. Disability and Rehabilitation: Assistive Technology 13(2):157-165.

5.  Moon, Y., and J. J. Sosnoff. 2017. Safe landing strategies during a fall: Systematic review and meta-analysis. Archives of Physical Medicine and Rehabilitation 98(4):783-794.