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.  

1          Scott V, Votova K, Scanlan A, Close J. Multifactorial and functional mobility assessment tools for fall risk among older adults in community, home-support, long-term and acute care settings. Age and Ageing 2007; 36: 130-139

2          Gillespie LD, Robertson MC, Gillespie WJ, Lamb SE, Gates S, Cumming RG, Rowe BH. Interventions for preventing falls in older people living in the community. Cochrane Database of Systematic Reviews 2009

3          Scuffham P, Chaplin S, Legood R. Incidence and costs of unintentional falls in older people in the United Kingdom. Journal of Epidemiology and Community Health 2003; 57: 740-744

4          Werner G. Strength and Conditioning Techniques in the Rehabilitation of Sports Injury. Clinics in Sports Medicine 2010; 29: 177-191

5          Zijlstra GA, van Haastregt JC, van Eijk JT, van Rossum E, Stalenhoef PA, Kempen GI. Prevalence and correlates of fear of falling, and associated avoidance of activity in the general population of community-living older people. Age Ageing 2007; 36: 304-9

6          Udell JE, Drahota A, Dean TP, Sander R, Mackenzie H. Interventions for preventing falls in older people: an overview of Cochrane Reviews. Cochrane Database of Systematic Reviews 2011

7          Gates S, Fisher JD, Cooke MW, Carter YH, Lamb SE. Multifactorial assessment and targeted intervention for preventing falls and injuries among older people in community and emergency care settings: systematic review and meta-analysis. BMJ 2008; 336: 130-3

8          Lamb SG, S. Fisher, J. Cooke, M. Carter, Y. & McCabe, C. Scoping Exercise on Fallers' Clinics. London, 2007

9          Chang JT, Morton SC, Rubenstein LZ, Mojica WA, Maglione M, Suttorp MJ, Roth EA, Shekelle PG. Interventions for the prevention of falls in older adults: systematic review and meta-analysis of randomised clinical trials. BMJ 2004; 328: 680

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

11        Tinetti ME, Speechley M, Ginter SF. Risk Factors for Falls among Elderly Persons Living in the Community. New England Journal of Medicine 1988; 319: 1701-1707

12        National Institute for Health and Clinical Excellence. Falls: The Assessment and Prevention of Falls in older people. Clinical Guideline 21. NICE, 2004

13        Pizzigalli L, Filippini A, Ahmaidi S, Jullien H, Rainoldi A. Prevention of Falling Risk in Elderly People: The Relevance of Muscular Strength and Symmetry of Lower Limbs in Postural Stability. The Journal of Strength & Conditioning Research 2011; 25: 567-574

14        Rydwik E, Frändin K, Akner G. Effects of physical training on physical performance in institutionalised elderly patients (70+) with multiple diagnoses. Age and Ageing 2004; 33: 13-23

15        Nadler SF, Malanga GA, Feinberg JH, Rubanni M, Moley P, Foye P. Functional Performance Deficits in Athletes with Previous Lower Extremity Injury. Clinical Journal of Sport Medicine 2002; 12: 73-78

16        Nadler SF, Moley P, Malanga GA, Rubbani M, Prybicien M, Feinberg JH. Functional deficits in athletes with a history of low back pain: A pilot study. Archives of Physical Medicine and Rehabilitation 2002; 83: 1753-1758

17        Kibler WB, Goldberg C, Chandler TJ. Functional biomechanical deficits in running athletes with plantar fasciitis. The American Journal of Sports Medicine 1991; 19: 66-71

18        Wiksrom EA, TIillman MD, Borsa PA. Detection of Dynamic Stability Deficits in Subjects with Functional Ankle Instability. Medicine & Science in Sports & Exercise 2005; 37: 169-175

19        Cook G. The Use of Fundamental Movements as an Assessment of Function - Part 1. North American Journal of Sports Physical Therapy 2006; 1: 62-72

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Warning: If you're a fan of Adele, probably best not to read this!

As Adele continues to conquer the charts both sides of the Atlantic (which is a fantastic achievement) her status as a role model also continues to grow. Hang on, what's Adele got to do with health, fitness etc, etc. Read on and I'll explain.

Now, my beef with Adele is that in a recent magazine interview (Flybe Uncovered - July 2011), when asked about industry pressures to look good, she said -

'if I'd never had a boyfriend because I was overweight, then obviously I'd lose some weight, but all the things I want I get, so I don't care.'

What the hell does that mean? After several re-reads I still don't fully understand what she is on about, but one thing is absolutely clear...she doesn't care she's overweight with or without a boyfriend by her side. What message is being put across to her young (and I'm sure old as well) followers? Answer, not a good one from a health and wellbeing stand-point.

And it doesn't end with that statement either, there's more. When asked whether she has considered going on a diet, Adele's riposte was quite astonishing -

'no, I like food, I don't like exercising.'

Hang on! What the hell has exercising got to do with that question?

'if I was affected by my weight I could easily lose weight now.'

Go on then, lose some weight, and at the same time benefit from getting fitter, getting stronger, sleeping better, standing better, improving your mood, speeding up your metabolism etc etc the list goes on.......

And just when I thought it couldn't get any worse....

'knowing my luck I'll get a Cheryl Cole body and I'd be about 30 by the time that happened and then I'd probably get pregnant so what's the point.'

The point, Adele, is that you are putting your health at risk by not being bothered to exercise. You have a gift of a wonderful voice which is part of an already great gift…your body. So look after it. It's not about weight, size, or figure...it's about your health! Whether you're fat, obese, skinny or average size, you should be exercising. I know you are happy with your body Adele, I'm very happy with mine too, but I exercise to reduce my risk of health related problems and so should you. Moreover, if you're not fit and healthy, then when the time comes don't expect your unborn baby to be either!

We all need to take more responsibility over our health, and all of us must be conscious about the messages we convey to our followers, be it our children, pupils or friends....more so if you have a massive world-wide following!

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My name is Spencer Brown, I am the founder and Director of Peak Performance Centre of Excellence Ltd (www.ppcoe.co.uk). We are specialists in physical conditioning and injury rehabilitation using the science, practice and principles of Strength & Conditioning (S&C).

Why have I decided to blog? I have been known on occasion to rant. Nothing unusual about that, but a few days ago I found myself ranting the same rant to everyone I came into contact with that day! So to save my clients, my partner and the dog from anymore outbursts, I decided to start a blog where I could share my frustrations with anyone who wanted to read them.

So here it is ...my first ever blog!

No I'm not going to rant, instead I will just explain a little more about what we do at Peak Performance (PPCOE), after which you may discover why I get frustrated from time to time.

At PPCOE we take individuals of all abilities and make them perform their sport better. We use sound proven principles of training with no gimmicks, flashy equipment, latest fads or expensive misleading marketing campaigns. Simply, if you participate in sport you need to be fit for that sport!

I've lost count the number of times I say this to people...maybe I should come up with another analogy? Your body, like your car, is your transport and is subjected to wear and tear so it's vitally important that you look after it. PPCOE has developed a comprehensive Functional Assessment procedure which can identify muscle imbalance, weakness and flexibility issues. All our clients get regulary assessed, along with other tests, to ensure they remain injury free and are able to train effectively. Therefore, look after your body...you only get one!

At PPCOE we don't tell you what you want to hear... we tell you straight! The internet, magazines, newspapers and television can be full of complete nonsense when it comes to health, fitness and exercise. Here at PPCOE we will help you sort the good (sometimes really great stuff) from the bad (frequently loads of it) and get you training, eating and living your life properly.

I hope now you understand a little more about how we go about things at PPCOE. We like to keep things simple, build upon good foundations and take it from there. There's no need to re-invent the wheel!

Please feel free to ask questions or challenge me about anything...a good debate (or rant) is healthy.

That's it for now and I hope you enjoy my blog posts.

Email me: spencer@ppcoe.co.uk

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