Everyone knows balance problems cause falls. How serious are falls? In older adults, falls can be very serious. Falls are a major cause of disability and the leading cause of death for people over 75 in the UK. One-third to one-half of people aged over 65 fall each year. Furthermore, over 400,000 older people in England attend accident and emergency departments following an accident. Over 86,000 hip fractures occur annually in the UK and 95% are a result of a fall. Up to 14,000 people die annually in the UK as a result of an osteoporotic hip fracture (National Service Framework for Older People 2001).
Most falls result in no serious injury, but approximately 5% of older people dwelling in the community and 10-25% living in care homes or hospital who fall each year will hospital care. Figures from the US show as many as 50% of the older adults who suffer a hip fracture will never regain their previous level of functioning and be able to live independently again. 50% of the people age 75 and over who fall and sustain a serious injury will die within a year as a result of the fall. Although most falls do not result in serious injury, the consequences of an individual falling or of not being able to get up after a fall can include: psychological problems, for e.g., a fear of falling and loss of confidence in being able to move about safely; loss of mobility leading to social isolation and depression, increase in dependency and disability hypothermia pressure-related injury infection.Falling, therefore has an impact on quality of life, health and healthcare costs.
Is it true most people do not know when they have a balance problem?
It’s very true. Most people, particularly young to middle age people, are totally unaware that they have a balance disorder. That’s because the human balance system has “back-ups”, so when sensory input from one source is inadequate, the central nervous system automatically turns to another source for orientation. In other words, a fully functioning part of the balance system will help do the work of a part of the system that is not fully functional.
The problem comes when people get older and have more than one part of their balance system that’s not 100% functional, and/or when they encounter an unusual situation and the working parts of their balance system are unable to compensate and overcome the unexpected “obstacle”. For example, an older person may have had a vestibular disorder (the great majority of balance problems are vestibular in nature) for many years but may have unconsciously compensated for that problem by relying on their keen eyesight to maintain their balance. But eyesight gets worse with age, and when coupled with dim lighting, poor eyesight often causes falls. That’s why many falls occur at night, when there may be little or no light available.
Can falls be prevented?
Many can. Most balance disorders are caused by some benign, easily treatable condition. In fact, one of the most common forms of balance disorder, benign paroxysmal positional vertigo (BPPV), can almost always be completely helped in 1 or 2 short therapy sessions. If your assessment reveals signs of a balance disorder, your practitioner may want you to have hearing and vision tests, as well as a physical evaluation. He or she may also order other diagnostic tests, such as an MRI, to help determine what is causing your balance problems. After the cause of your problem has been determined, because 80-85% of all balance problems respond well to specific therapeutic manoeuvres and exercises, your physician may decide that you would benefit from balance therapy or gait therapy. If so, he or she will order it, and a therapy regimen will then be custom-tailored to your specific problem. Your therapy may involve eye-tracking exercises, for example, in which you hold a card in front of you and move your head rapidly from side to side, in opposite directions, while keeping the words on the card in focus. Other exercises involve such simple movements as getting in and out of a chair several times in succession each day.
Why screen older patients for balance problems?
First, don’t be alarmed if your balance score is abnormal for a person of your age. Balance problems can be caused by such common things as a cold or flu, lack of sleep, the effects of medications or even too much caffeine. In those cases the problem will usually resolve itself without any medical intervention. But balance problems and dizziness can also be the first sign of serious health problems such as brain tumours, anaemia, Parkinson’s disease, multiple sclerosis, diabetes, strokes, high blood pressure, traumatic injuries and many, many others. That’s why identifying patients with abnormal balance can be invaluable in the detection of other serious conditions. There’s also another reason. Balance system assessment helps your physician identify patients who may be at an increased risk of falling. In older patients, falls can result in broken hips, other fractures, head trauma and other serious injuries, even death.
That’s why in the US, Clinical Practice Guideline recommends the routine screening of all older persons. So if your results show signs of a balance disorder, and if the reason is not immediately apparent, your physician will want to find out why. But please keep in mind that balance disorders are almost always caused by some benign, easily treatable condition. The major risk factors for falling are diverse, and many of them such as balance impairment, muscle weakness, polypharmacy and environmental hazards are potentially modifiable. Since the risk of falling appears to increase with the number of risk factors, multifactorial interventions have been suggested as the most effective strategy to reduce declines in function and independence and also to prevent the associated costs of complications.
Preventive programmes based on risk factors for falling include exercise programmes, education programmes, medication review, environmental modification in homes or institutions and nutritional or hormonal supplementation. Interventions need to target extrinsic factors such as hazards within the home environment and intrinsic risk factors such as mobility, strength, gait, medicine use and sensory impairment. Numerous interventions have been studied in the prevention of falls. Few trials have been carried out in the UK. The prevention and management of falls in older people is a key government target in reducing morbidity and mortality.
References to the above:
American Academy of Orthopaedic Surgeons, Don’t let a fall be your last trip,1998; CDC,
National Centre for Injury Prevention and Control, Preventing Injuries Among Older Adults, 2001-2002;
NICE The Assessment and Prevention of Falls in Older People (Final Draft 2004)
Vestibular Technologies promotional leaflet All patients over 55 should be regularly screened for risk of falling
Evidence based summary for manual therapy
Moderate quality evidence that manual treatment (specifically sustained natural apophyseal glides) is an effective treatment for cervicogenic dizziness, at least in the short term .
There is evidence that benign paroxysmal positional vertigo (BPPV) is effectively treated by manual therapy procedures such as the Epley manoeuvre. [Cohen HS, Kimball KT. Effectiveness of treatments for benign paroxysmal positional vertigo of the posterior canal. Otol Neurotol. 2005;26:1034-1040. von Brevern M, Seelig T, Radtke A, et al. Short-term efficacy of Epley’s manoeuvre: a double-blind randomised trial. J Neurol Neurosurg Psychiatry. 2006;77:980-982. Tanimoto H, Doi K, Katata K, et al. Self-treatment for benign paroxysmal positional vertigo of the posterior semicircular canal. Neurology. 2005;65:1299-1300].
Other effective non-invasive physical treatments or patient education
Particle repositioning manoeuvres for benign paroxysmal positional vertigo, vestibular rehabilitation [25,28]
Back-in-Action clinical comment
The balance system relies on information from the position sense of the joints and muscles (particularly of the neck), the vestibular system (inner ear ‘spirit levels’) and the eyes. Information from these areas is integrated in certain brain areas which also need to be working well for healthy balance. Chiropractors treat dizziness and vertigo using a package of care that may include manual therapies and onward referral where indicated. A thorough functional neurological assessment is of primary importance. Treatment may include functional neurological exercises (vestibular, eye, cerebellum etc.), chiropractic spinal manipulation, cranial work, muscle release techniques, ergonomic advice, relaxation advice, postural advice, acupuncture, breathing techniques, neck exercises, jaw exercises. These disorders may be co-managed medically or with physiotherapists or dental practitioners.
There is evidence to support this approach to patient care [29,20].
From the Preston Chiropractor Team
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