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Role of the Musculoskeletal System
and the Prevention of Falls
Marcel Fraix, DO, FAAPMR
Assistant Professor
Department of Physical Medicine and Rehabilitation
Western University of Health Sciences
Objectives
Epidemiology of Falls in the Older Adult Population
Risk Factors for Falls
Evaluation of the Patient at Risk for Falling
Preventing Falls in the Older Adult Population
Epidemiology of Falls
30% of adults > 65
within the community
fall once per year
Falls are leading cause
of fatal and non-fatal
injuries in older adults
Annual cost of fall
related injuries
expected to reach
$32.4 billion in 2020
Centers for Disease Control and Prevention (CDC). Self-reported falls and fall-related injuries among
persons aged⩾65 years —- United States, 2006. MMWR Morb Mortal Wkly Rep. 2008;57(9):225-229
Epidemiology of Falls
Fall Related Injury
• Fracture
Impairment
• Immobility
Hospitalization
• SNF Placement
Stevens JA. Falls among older adults—risk factors and prevention strategies. In: Falls Free—Promoting a National
Falls Prevention Action Plan: Research Review Papers. Washington, DC: The National Council on the Aging; 2005
Risk Factors for Falls
Falls
Environment / Medication
Impaired Strength / Balance
Vitamin D Deficiency
Vitamin D Deficiency
25-hydroxyvitamin D
10 - 55 (ng/mL)
25 – 137 (nmol/L)
Deficiency
40 % of older adults with no history of falls
70 % of adults with history of falls
Gloth MF, Tobin JD. Vitamin D deficiency in older people. J Am Geriatr Soc. 1995;43(7):822-828
Vitamin D Deficiency
25-hydroxyvitamin D
Bone metabolism
Muscle metabolism
Ca2+ and PO4
Cell maturation
Deficiency
Decreased BMD
Diminished strength
low 25-hydroxycholecalciferol
increases risk of sarcopenia in
individuals > 65
Visser M, Deeg DJ, Lips P; Longitudinal Aging Study Amsterdam. Low vitamin D and high parathyroid hormone
levels as determinants of loss of muscle strength and muscle mass (sarcopenia): the Longitudinal Aging Study
Amsterdam. J Clin Endocrinol Metab. 2003;88(12):5766–5772
Impaired Strength and Balance
Impaired strength and
balance predispose older
adults to falls
Decreased strength
Diminished postural
equilibrium
Somatic Dysfunction
Medication
Sedatives / Pain
Medications
Benzodiazepines
Opioids
Insomnia medications
Anti-depressants
Trazadone
Mirtazipine
Somatic Dysfunction
Somatic Dysfunction
Asymmetry
Restricted ROM
Impaired components of
gait are predictors for fall
Step length
Postural sway in the
anterior posterior direction
Kerr GK, Worringham CJ, Cole MH, Lacherez PF, Wood
JM, Silburn PA. Predictors of future falls in Parkinson
disease. Neurology. 2010;75(2):116-124
Evaluation of the Patient at Risk for Falling
Multifaceted Approach
Screening for risk factors
Physical Exam
Neurological
Motor Strength
Sensation
Proprioception
Vestibular Function
Balance
Vision
Musculoskeletal
ROM
Posture
Somatic Dysfunction
Michael YL, Whitlock EP, Lin JS, et al. Primary care-relevant interventions to prevent falling in older adults:
a systematic evidence review for the U.S. Preventive Services Task Force. Ann Intern Med.
2010;153(12):815-825
Preventing Falls
Multifaceted Approach
Screen and evaluate for risk
factors
Diagnostic testing
Vitamin D deficiency
Osteopenia / Osteoporosis
History / Physical Exam
Medications
Motor Strength / Balance
Home environment
Intervention for specific risk
factors
Falls
Environment / Medication
Impaired Strength / Balance
Vitamin D Deficiency
Preventing Falls
Vitamin D Supplementation
Influences Bone Density
Influences Muscle and Nerve Function
Improves muscle strength and
postural equilibrium
Pfeifer et al.
800 IU Vitamin D and 1000 mg Ca
daily over 12 month period for
242 older adults
# of 1st falls down 27% at
month 12 and 39% at month 20
Treatment group significantly
increased leg extensor strength
and decreased postural sway
Pfeifer M, Begerow B, Minne HW, et al. Effects of a long-term vitamin D and calcium supplementation on
falls and parameters of muscle function in community-dwelling older individuals. Osteoporos Int.
2009;20(2):315-322
Preventing Falls
Vitamin D Supplementation
Variability
Sex
Age
Ethnicity
Baseline 25-hydroxyvitamin D
Level
Ca Supplementation
From Connie M Weaver and James C Fleet, Vitamin D
requirements: current and future Am J Clin Nutr
2004;80(suppl):1735S–9S
Preventing Falls
Strength and Balance
Control
Exercise reduces the fall
rate in older adults
Exercise dose
Benefits seen after >
50 hours of training
Type
Balancing training
Weight bearing
Sherrington C, Whitney JC, Lord SR, Herbert RD, Cumming RG, Close JC. Effective exercise for the
prevention of falls: a systematic review and meta-analysis. J Am Geriatr Soc. 2008;56(12):2234-2243
Preventing Falls Types of Exercise Appropriate for Older Adults Based on Level of Fall Risk
Level of Fall Risk Type of Exercise
Low (no history of falls or fall-related risk
factors)
Community-based exercise programs (eg, tai
chi, dancing, walking program)
Moderate (history of 1-2 falls in past or
presence of 1 or more fall-related risk
factors)
Physical therapy (eg, strength training)
to target specific strength and coordination
deficits
Dynamic balance and posture control
training
Transition to community-based exercise
programs if appropriate
High (injury-related fall within past 6 mo or
presence of 2 or more fall-related risk
factors)
Physical therapy (eg, strength and balance
training in seated or supported standing
position, weight shifting and transfer
training, gait training, no independent
walking program) to target specific strength
and coordination deficits
Rose DJ, Hernandez D. The role of exercise in fall prevention for older adults. Clin Geriatr Med.
2010;26(4):607-631
Preventing Falls Home Modification
Eliminate tripping hazards and low light
Use of grab bars and anti-slip mats
In home visit
Medication
Judicious use
Benzodiazepines
Opioids
Insomnia medication
Decreased fall risk with decreased dosage and number of medications
Campbell AJ, Robertson MC, Gardner MM, Norton RN, Buchner DM. Psychotropic medicine withdrawal and a
home-based exercise program to prevent falls: a randomized, controlled trial. J Am Geriatr Soc.
1999;47(7):850-853
Preventing Falls
Somatic Dysfunction
Osteopathic Manipulative
Treatment (OMT)
Wells et al found
significant improvement
in parameters of gait
(stride length, cadence,
extremity velocity) when
using OMT to treat
patients with Parkinson’s
Disease
Wells MR, Giantinoto S, D’Agate D. Standard osteopathic manipulative treatment acutely improves gait
performance in patients with Parkinson’s disease. J Am Osteopath Assoc. 1999;99(2):92-98.
Fall-Related Risk Factors and Interventions to Reduce the Risk of Falling in
Older Adults
Fall-Related Risk Factor Intervention
Vitamin D deficiency Vitamin D supplementation (eg, 800 IU daily)
Decreased strength or balance control Exercise program based on level of fall risk
Environmental hazards Home-hazard modification (eg, tripping
hazards, dim lighting); in-home visits
Medication Reduction or elimination of medication
(eg, sedatives and hypnotics,
antidepressants, benzodiazepines)
Somatic Dysfunction OMT