Almost 30 Screening Tools for Fall Risk Assessment Available...So Why are Elderly People Still Falling?
As the population aged >60 years grows, the number of falls and subsequent injuries increases 1. Aging is associated with a number of physiologic and functional declines that can contribute to an increase risk of falling 2. In the UK during 1999, there were 647,721 accident and emergency attendances and 204,424 admissions to hospital for fall related injuries in people aged 60 years and over 3. Several systematic reviews 1, 2, 6-9 show limited evidence of effectiveness of current screening tools and subsequent falls clinics. One issue is the fact that fall risk profiles and interventions differ greatly among healthy and able-bodied elderly people living in the community; those who require on-going care within the community; those in long-term care facilities (LTC); and those who are hospitalised for other illnesses 10. Arguably, elderly people who require LTC and/or are hospitalised should receive a fall risk assessment as standard protocol due to their relatively high risk compared to healthy community living people. In the absence of empirical evidence health services need reliable and effective screening tools to highlight at-risk community dwelling elderly individuals in order to guide targeted interventions. In the community setting many modifiable physical factors exist which have been shown to contribute to an older persons risk of falling 11. These include gait and balance deficit and/or biomechanical alignment and muscle strength and power 12. Current Fall Risk Screening Tools Knowing the above one would assume that current fall risk screening tools would clinically assess these modifiable risk factors. However, this doesn’t seem to be the case. The ProFANE Taxonomy Domain 1 (A509) 10 describes a fall screening tool as a short test to determine an older persons risk of falling so that they can become eligible for a fall risk reduction intervention programme. A large number of tools are available covering various components of fall risk including visual, mental, cardiovascular and physical health. Physical health can be further subdivided into gait and balance ability, muscle weakness and perceived functional ability, all of which have been identified as high risk factors 12. Currently, little evidence exists as to the reliability and effectiveness of fall risk screening tools and fallers’ clinics in the UK 2, 6-9. This may in part be due to the fact that a lack of consistency in reporting methods and varying interpretations of fall risk assessment tools across studies 1. It may also be possible that screening tools are being used in the wrong setting and therefore do not reflect the purpose to which the tool is being applied. Another factor for the lack of evidence is the many different assessments that are used to determine a person’s physical impairment. For example, a review in Canada 1 identified 14 studies which tested 23 different tools assessing for fall risk in a community setting. This makes comparisons across studies almost impossible due to screening test interpretation, cut-off points and differences in reporting methods and study populations. Similarly, a review in 2007 8 reported 28 screening tests were used in a community setting. On closer inspection of the literature, few screening tools were examined by more than one study, and where studies used the same tool there were differences in the performance and cut-off values to predict a positive test. Lower Body Strength & Balance Training? According to the literature tests of gait and balance seem to have made up the majority of screening tools. However, it is questionable how sensitive these tests are at predicting fallers 8 as these tests are not designed to assess biomechanical alignment issues, quantify strength levels in the lower body muscles, flexibility range and imbalances. As strength has been widely linked to fall risk 13 in the elderly it is therefore necessary to include this measure as part of a screening tool. Research has demonstrated that strength training alone (fixed resistance machines and/or non-functional strengthening) is not enough to improve balance, but rather a combination of both strength and balance training is most likely to reduce fall risk 14. Given the finding that muscular weakness is a risk factor for falls the obvious question is 'can strength training prevent falls?'. To answer this question a screening tool would need to have the capacity to adequately and reliably measure strength in the lower body, not just the lower limb. It is not practical or cost effective to measure strength using expensive machines however it is possible for a qualified professional to do so using existing strength tests. Physiotherapists and sports therapists are well trained in these simple tests to determine the strength and integrity of an individual and whole muscle groups. These tests are relatively quick to administer and easily learned. Interestingly, one aspect of fall prevention which has received little attention is the role of muscle weakness in the ability to recover from a trip or fall. Most, if not all, screening tools and interventions focus on strength to overcome gait and balance impairments which are typical with ageing. This strength requirement would increase a person’s reaction and evasive ability in order to overcome an obstacle. However, another theory would assess the patient’s ability to recover from an off-balance situation so that a fall can be prevented. It could be argued, that elderly people are at higher risk of falling not because they trip or stumble but rather due to their inability to successfully recover from it. Clearly it is important that an assessment of strength forms part of an initial screening test and some form of targeted strength training intervention follows. Gait and balance training needs to be more specific to each individual including a focus on recovering from, as well as prevention of, falling. Movement Competency? A battery of assessment screening tools is available to rehabilitation and conditioning professionals within elite and/or professional sports settings. Typically, these evaluations are multifactorial in nature and cover multiple aspects of human movement and performance. Research has demonstrated that isolated joint/muscle rehabilitation approaches are not sufficient enough to return the athlete to normal performance levels 15. This is due to the whole-body nature of human physical performance and the observation that other areas of the kinetic chain can be affected after injury 15-18. As such, the screening tools used within elite sport are designed to identify asymmetries and areas for performance improvement (of a specific physical task) rather than solely offering an objective score of task performance ability. They are required to be sufficiently sensitive to more accurately prescribe conditioning and rehabilitation/remedial interventions. Another obvious question, then, is 'can primary care learn from professional/elite sports rehabilitation methodology?' Or, if they already know, why isn't this type of screening/assessment approach being used throughout the NHS? One of the most popular screening tools in current use is the functional movement screen (FMS) which has been developed and described by Grey Cook 19. The FMS consists of seven fundamental movement tests which have been chosen to categorise functional patterns. It is conceptualised by the fact that each test movement forms the basis of more complex movements which all humans experience in every-day activities, sporting or non-sporting. I am not aware of any other validated screening tool existing within elite sport (please correct me if I am wrong on this point), rather, adaptations and variations of the FMS concept are being designed by S&C coaches and physiotherapists based on specificity of the task required for a particular sport and participant. Thus, my argument is based around the conceptualisation of basic movement asymmetry, muscle weakness and decreased functional ability being an early warning system for detection of more serious MSK issues in the future. Clearly, the FMS in its present form would be far too difficult for elderly persons to perform but we should focus not on the exercises in it but more so on what the FMS is designed to do....prevent injury and facilitate performance improvements. Arguably, fall risk screening tools that measure physical ability currently in use need to go further and be more sensitive so that strength deficits, balance impairments and dysfunctional movement characteristics can be identified. Future screening and assessments tools would benefit from establishing ‘how well’ a patient performs a given task as well as ‘can they’ perform a task and have the sensitivity to highlight the reason why. Clearly, researchers and health professionals would benefit from a single comprehensive functional assessment screen which identifies modifiable physical risk factors (gait & balance deficits, strength deficits, flexibility and biomechanical alignment). Furthermore, a single screening tool would minimise heterogeneity across studies examining fall risk in elderly people.
10 Lamb SE, Hauer K, Becker C. Manual for the fall prevention classification system. http://www.profane.eu.org/documents/Falls_Taxonomy.pdf volume 2011, 2007
