Appropriate Rehabilitation Methods & Strategies to Prevent Fall Recurrence for the ‘Active’ Patient

As older adults maintain more active lifestyles to help manage chronic conditions such as diabetes, helping to reduce repeat falls may be as important for wound care providers as is teaching general fall prevention.

Most patients requiring treatment in the hospital-based outpatient department (HOPD) will present with wounds associated with chronic disorders such as diabetes, venous insufficiency, and/or debilitation secondary to aging. This particular sector of the population is the same demographic with the highest risk, as well as the highest incidence, of falls.^1-4 Frequently subsequent to falls may be skin injuries that develop into problematic wounds. With this backdrop, it’s interesting to note that wound care specialists commonly focus their attention on etiologies of wounds that do not include falls. Wound prevention and reoccurrence strategies rarely, if ever, focus on fall prevention and rehabilitation. This article will discuss this subject and will refer to an expansive array of sources from which these fall injuries emanate.

The “Active” Wound Care Patient

Let’s address our attention to the active person younger than 65 years of age who experiences a fall as a result of a slip or a trip associated with an activity or sport such as running, biking, hiking, or tennis. The injury sustained can be physically and mentally consuming, especially as it pertains to the patient’s frustration with perhaps not being able to go to the gym, the court, or the track while rehabbing the injury. According to the Centers for Disease Control and Prevention (CDC), falls are the No. 1 cause of injuries and death from injuries for older Americans. In 2014, older Americans had 29 million falls that caused 7 million injuries. About 28,000 seniors ages 65 and older died from falls in 2014, the CDC reported. Agency officials believe these numbers could surge as more than 10,000 Americans are turning 65 each day.

Additionally, about one-third of the United States population older than age 65 experiences a fall each year, and the risk of falls increases proportionately with age.³ At 80 years, over half of seniors fall annually. Those living with diabetes, a majority constituent in the wound clinic, have a higher risk and incidence of falling. However, not every fall results in an injury or a wound. 

According to a study by Yale University researchers,⁵ 47% of fallers are not injured, but in some instances can’t get up on their own. For those in this category, the period of time spent immobile often affects functional outcome. Muscle cell breakdown starts to occur within 30-60 minutes of compression due to falling, according to the American Geriatric Society. Dehydration, pressure ulcers, hypothermia, and pneumonia are other complications that may result. Getting help after an immobilizing fall is therefore critical and improves the chance of survival by 80% while increasing the likelihood of a return to independent living. Conversely, 53% of fallers are injured and most either develop skin wounds or develop conditions that will lead to chronic, life-threatening ulcerations.⁵ For instance, hip fractures are among the most common of injuries subsequent to falls. 

Alternatively, more than 95% of hip fractures among older women are caused by falling.⁶ There is a substantial connection between this injury and pressure-related ulcerations. Other considerations that may be important to wound care providers may be the link between those living with wounds and diabetes. It’s also interesting to note that up to 40% of people who have experienced a stroke have a serious fall within the next year and are then faced with the high risk of wounds.

Workplace Falls Prevention

Additionally, a substantial portion of falls occurs in the professional workplace, where causes of accidents can be easily identified and lead to simple implementation of prevention policies. With an eye towards prevention, the leading causes of workplace injuries include: a floor that’s slippery due to a wet or oily surface, materials and debris remaining from construction scenes, uneven floors or working surfaces in need of repairs, protruding nails, bunched-up floor mats or uneven carpeting, holes or depressions in working surfaces, stairway step-risers that are not uniform in height, and misplaced ladders.^7-9

Focus on Footwear & Fall Prevention

The activity/sports/workplace injuries discussed in this article have not yet taken into consideration the possibility that the individual may be wearing inappropriate shoes or may be experiencing a lack of attentiveness or dizziness due to a medical condition, medication, or even the use of recreational drugs at the time of the injury/accident. 

Educating patients on the importance of wearing appropriate footwear depending on the person’s activities of interest and/or work setting can be as essential to fall prevention as is educating them about drug and alcohol use or medication/disease management. Proper orthotics and quality, supportive footwear should be encouraged. Patients should also be instructed to have their vision checked and homes cleared of hazardous obstacles. 

As in most areas of healthcare, prevention is the best treatment. But in the wound clinic, the clinician’s first encounter with a patient may be following an initial fall. Preventing falls from becoming recurrent is a many-faceted issue that the wound care provider can and should discuss with patients. 

Terri Brusseau Kraus, MPT, a clinician in the North County San Diego area who is well known for her expertise in fall prevention, stresses the need for an intricate balance of relevant muscle groups and working with how they relate to the mechanisms of falling. She states that fall prevention is a complex issue that requires regard for the “whole person.” The most important factors are posture, body mechanics, strength, range of motion, and, in the patient living with diabetes, attending to potential and current diabetic complications such as neuropathy, poor vision, and gait issues. Minimizing extrinsic fall risks and environmental hazards is also critical to fall prevention.¹⁰

Posture is also a key component to decreasing fall risks. Most activity occurs “in front of” an individual. As the head goes forward during an activity, the shoulders roll in, the pelvis shifts anteriorly, and weight moves towards the toes and lateral quadriceps. In this posture, it is more difficult to lift one’s feet, resulting in a “shuffle gait.” This anterior weight shifting also makes stopping the forward momentum generated in gait difficult, and falls can easily occur. 

Body mechanics are essential in helping to prevent falls. Transitional moves such as getting up from a seated position (again often done in a forward weight-shifted position) by using a pulling motion of the quadriceps versus a pushing motion of the gluteals and hamstrings challenges one’s balance. More involved tasks, such as getting in and out of a car, walking on uneven surfaces, or walking up/down stairs are all fall risks that can be diminished with improved posture, body mechanics, and strength training. 

Strength training of the lower extremities and core is vital to improve balance and lessen falls. People must be taught to use their gluteus maximus and hamstrings for leg and hip extension and to build their gastrocnemius and soleus to assist in controlling gait, especially when descending curbs or stairs.In gait, stance and transitional movement, gluteus medius, and transverse abdominal strength are crucial for hip control and maximizing power generation of the legs and spinal endurance used in stance and upright posture. Hip adductors should also be emphasized to centralize balance. Back, hip, knee, and ankle range of motion are important to address in fall prevention. 

Again, neutral alignment is the goal. If any joint is hypo- or hypermobile, it throws the chain sequence off and adjustments need to be made. Other medical conditions, such as peripheral neuropathy of the feet and extreme supination or pronation, are also major contributors to increasing fall risks. Increasing tactical awareness of the foot with massage to aid in blood flow and mental connection to a limb can help patients “reconnect” with their feet. 

According to Art Helfand, DPM, a podiatric physician, surgeon, and an expert on falls, “It must be recognized that the foot is a keystone in support and balance; and that common foot problems, such as heloma, tyloma, hallux valgus, rigidus, and any other condition of the lower extremity which modifies support and/or balance can contribute to a fall. There is now strong evidence that foot problems have a detrimental effect on balance and are an independent risk factor for falls.”^11,12

Summary 

The current paradigm in which care is practiced in the wound care clinic can be expanded. Teaching patients neutral posture and good body mechanics aligns the spine and redistributes weight in a more functional manner for all activities. Increasing one’s lower extremity strength and abdominal muscles allows the body to hold a steadier stance with less effort. Proper range of motion in the back and lower extremities allows a person to more easily stack body weight over the feet and allow the core to work more efficiently. Picking up one’s feet is improved, weight shifting is enhanced, balance is optimized, and fall risk diminishes. 

Kenneth B. Rehm is board certified by the American Board of Multiple Specialties in Podiatry, for which he sits on the board of directors as treasurer. He currently serves as medical director at Diabetic Foot & Wound Treatment Centers Inc., San Marcos, CA, and as medical director of the Cardiovascular, Diabetes and Limb Preservation Alliance.  He is also president and chief executive officer of KBR Health Products, San Marcos, and Dr. Rehm Remedies (www.drrehmremedies.com). He may be reached at 760-744-6226.

References

1.  Pieper B. Chronic venous insufficiency and fall risk. Presented at 43rd Annual Conference Wound, Ostomy and Continence and Nurses Society.

2. Crews RT, Yalla SV, Fleischer AE, Wu SC. A growing troubling triad: diabetes, aging, and falls. J Aging Res. 2013. Accessed online: https://dx.doi.org/10.1155/2013/342650

3. World Health Organization. What are the Main Risk Factors for Falls Amongst Older People? 2004.

4. Tilling LM, Darawil K, Britton M. Falls as a complication of diabetes mellitus in older people. J Diabetes Complications. 2006;20(3):158–62. 

5. Tinetti ME, Liu WL, Claus EB. Predictors and prognosis of inability to get up after falls among elderly persons. JAMA. 1993;269(1):65-70.

6. Thacker SB, Branche C. Reducing Falls and Resulting Hip Fractures Among Older Women. Centers for Disease Control and Prevention. 

7. Slips, Trips and Falls Fact Sheet. North Carolina Department of Labor. Accessed online: www.nclabor.com/osha/etta/A_to_Z_Topics/SlipsTrips.pdf

8. Preventing Slips, Trips, and Falls in Wholesale and Retail Trade Establishments.Workplace Solutions. Centers for Disease Control and Prevention. Accessed online: https://www.cdc.gov/niosh/docs/2013-100/pdfs/2013-100.pdf

9. Slip, Trip, and Fall Prevention for Healthcare Workers. Centers for Disease Control and Prevention. Accessed online: https://www.cdc.gov/niosh/docs/2011-123/pdfs/2011-123.pdf

10. Rehm K. Oral interview.  Terri Brusseau Kraus. 15 Aug 2016.

11. Arthur Helfand A. Foot impairment — an etiologic factor in falls in the aged. J Am Podiatr Med Assoc. 2;97(4):304-9. 

12. Rehm K. Oral interview. Art Helfand.17 Aug 2016.