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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

Role of the Musculoskeletal System and the Prevention of …ws.westernu.edu/WesternU-News/docs/CME-2012-Fraix.pdf · Role of the Musculoskeletal System and the Prevention of Falls

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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

Environment

Home Hazards

Tripping hazards

Rugs

Low standing furniture

Dim lighting

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

Thank you!

JAOA

Evidence-Based Clinical Review

Fraix, M. Role of the musculoskeletal system and the

prevention of falls. J Am Osteopath Assoc. 2012 Jan;112(1):17-

21. PMID: 22302742