ChiroACCESS Article



Fall Prevention: How Can Chiropractors Be Involved?



This information is provided to you for use in conjunction with your clinical judgment and the specific needs of the patient.

Cheryl Hawk, DC, PhD, CHES

  

Cleveland Chiropractic College



Published on

November 11, 2007

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Public Health Significance of Falls in Older Adults

Falls in older adults are becoming an increasingly important issue for the public, for health care providers, and for society in general. Each year, approximately one-third of community-dwelling adults aged 65 or older experience a fall.1 Falls cause two thirds of all unintentional injury deaths in older adults.2 Of those older adults hospitalized due to falls, 40-50% lose their independence and enter a nursing home as a result.1 According to a 2005 study, the direct medical costs of falls are estimated to be $6-8 billion per year.3 Furthermore, not only is the population of older adults growing rapidly, but fall death rates are on the rise for both men and women.4

Approaches to Fall Prevention

The scientific community, healthcare providers and community groups are working together more and more to develop successful fall prevention interventions. In fact, evidence-based guidelines for fall prevention have been developed and adopted by many community and provider groups, both nationally and internationally.5-8 Guideline recommendations for fall prevention strategies focus on risk factor identification and modification.

The American Geriatric Society (AGS) clinical practice guidelines recommend that:8

1. Clinicians should ask older adults annually about falls. The Prevention of Falls Network Europe and Outcomes Consensus Group recommends asking patients, “Have you had any fall including a slip or trip in which you lost your balance and landed on the floor or ground or lower level?” 7,8

2. Older adult patients who report a fall should be screened for risk factors. The most important modifiable risk factors for falls in older adults are:

• Impaired mental status

• Use of psychotropic medications which may impair cognition and balance

• Polypharmacy

• Environmental hazards

• Poor vision

• Lower extremity weakness and/or dysfunction

• Impairments in balance, gait and activities of daily living

3. Interventions should be multifactorial and should target the individual’s identified risk factors. Recommended clinical interventions include:

• Gait training

• Balance exercises, such as those recommended by the National Institute on Aging (NIH) of the National Institutes of Health 9

• Review and modification of medications

• Treatment of postural hypotension

• Home hazard correction

• Management of cardiovascular disorders

• Vision correction


Does Chiropractic Manipulation Help?

The American Geriatric Society’s (AGS) 1998 guidelines on the management of chronic pain included chiropractic care as a non-drug approach to pain management which had been helpful in some and demonstrated few adverse effects.10 There is substantial evidence for beneficial effects of spinal manipulation for spine-related pain.11,12 Chiropractic care may therefore affect gait and balance through ameliorating musculoskeletal pain. The scientific literature also suggests that spinal manipulation may positively impact certain types of vertigo.13 However, to date, only two studies have been published which investigate the effect of chiropractic care on balance in older adults, within a context of fall prevention—the author of this article was the principal investigator of both.14,15 Certainly this is an area that warrants further research.


What Can Chiropractors Do to Promote Fall Prevention?

To incorporate the current evidence-based guidelines into their practice, chiropractors should include the following:

1. History of falls. Add this question to initial and assessment forms: “Have you had any fall including a slip or trip in which you lost your balance and landed on the floor or ground or lower level?”

2. Risk factor inventory for at-risk patients. Include, at a minimum, the following:

• Medication history (refer patient back to his/her primary care physician as appropriate)

• Date of last eye exam, and current use of glasses/contact lenses (refer patient to his/her optometrist as appropriate)

• Health history, including dizziness, visual disturbances, musculoskeletal conditions and injuries.

• Physical examination, including blood pressure, evaluation of possibly dehydration (using the “pinch test”) and body mass index

• Diet and lifestyle assessment, including fluid intake, smoking, alcohol use, and physical activity

• Lower body weakness, dysfunction, and balance problems. A simple screening assessment is the One Leg Standing Test (OLST): The patient stands on each leg as long as possible without touching the other foot to the floor or losing balance, eyes open. The doctor records the time in seconds for each leg. Based on earlier studies and clinical experience, the recent studies of chiropractic and balance consider patients over 65 with an OLST time < 5 seconds to have impaired balance.14-16

3. Home-hazard checklist. Follow up with them about it on subsequent visits. Several informational brochures are available from the National Center for Injury Prevention and Control. A Toolkit to Prevent Senior Falls (http://www.cdc.gov/ncipc/pub-res/toolkit/toolkit.htm).

4. Exercises to improve balance. A free downloadable booklet is available through the NIA: Exercise: A Guide from the National Institute on Aging (http://www.niapublications.org/exercisebook/ExerciseGuideComplete.pdf). Tai chi or any gentle exercise program designed to strengthen the lower body are also beneficial.

5. Chiropractic care to resolve musculoskeletal pain and dysfunction. Monitor over time to prevent recurrences and to promote optimal function.


It is important for chiropractors to provide their older patients with fall prevention information and interventions, in order to serve their patients’ best interests. However, it is also important for chiropractic as a profession, in order to demonstrate its integration into national and international prevention initiatives.
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References

1.   

Lajoie Y, Gallagher SP. Predicting falls within the elderly community: comparison of postural sway, reaction time, the Berg balance scale and the Activities-specific Balance Confidence (ABC) scale for comparing fallers and non-fallers. Arch Gerontol Geriatr 2004;38(1):11-26.



2.   

Tinetti ME. Clinical practice. Preventing falls in elderly persons. New England Journal of Medicine 2003;348(1):42-49.



3.   

Carroll N, Slattum P, Cox F. The cost of falls among the community-dwelling elderly. J Manag Care Pharm 2005;11(4):307-316.



4.   

National Center for Injury Prevention and Control. A Toolkit to Prevent Senior Falls: http://www.cdc.gov/ncipc/pub-res/toolkit/toolkit.htm.



5.   

Moreland J, Richardson J, Chan DH, et al. Evidence-based guidelines for the secondary prevention of falls in older adults. Gerontology 2003;49(2):93-116.



6.   

Hauer K, Lamb SE, Jorstad EC, Todd C, Becker C. Systematic review of definitions and methods of measuring falls in randomised controlled fall prevention trials. Age Ageing 2006;35(1):5-10.



7.   

Lamb SE, Jorstad-Stein EC, Hauer K, Becker C. Development of a common outcome data set for fall injury prevention trials: the Prevention of Falls Network Europe consensus. J Am Geriatr Soc 2005;53(9):1618-1622.



8.   

American Geriatric Society. Guideline for the prevention of falls in older persons. American Geriatrics Society, British Geriatrics Society, and American Academy of Orthopaedic Surgeons Panel on Falls Prevention. J Am Geriatr Soc 2001;49(5):664-672.



9.   

National Institute on Aging. Exercise: A Guide from the National Institute on Aging. http://www.niapublications.org/exercisebook/ExerciseGuideComplete.pdf



10.   

American Geriatric Society. The management of chronic pain in older persons: AGS Panel on Chronic Pain in Older Persons. J Am Geriatr Soc 1998;46(5):635-651.



11.   

Bigos S, Bowyer O, Braen G, et al. Acute Low Back Problems in Adults. Clinical Practice Guideline No. 14; 1994.



12.   

Meeker W, Haldeman S. Chiropractic: a profession at the crossroads of mainstream and alternative medicine. Ann Intern Med. 2002;136(3):216-227.



13.   

Reid SA, Rivett DA. Manual therapy treatment of cervicogenic dizziness: a systematic review. Man Ther 2005;10(1):4-13.



14.   

Hawk C, Rupert R, Colonvega M, Hall S, Boyd J, Hyland J. Chiropractic care for older adults at risk for falls: a preliminary assessment. J Am Chiropr Assoc 2005;42(September/October):10-18.



15.   

Hawk C, Pfefer MT, Strunk R, Ramcharan M, Uhl N. Feasibility study of short-term effects of chiropractic manipulation on older adults with impaired balance. J Chiropr Med (in press).



16.   

Bohannon RW, Larkin PA, Cook AC, Gear J, Singer J. Decrease in timed balance test scores with aging. Phys Ther 1984;64(7):1067-1070.