There is little doubt that rheumatic diseases such as osteoarthritis (OA) and rheumatoid arthritis (RA) significantly increase the risk of falls, but historically there has been limited emphasis on the need to prevent falls from occurring in these patients. What can rheumatologists do? Start by assessing risk for the individual patient. Inform these patients about activities that have been shown to prevent falls and make referrals to providers who can facilitate their participation in these activities. In short, says Debra J. Rose, PhD, co-director of the Center for Successful Aging at California State University in Fullerton, “get the patient to embrace physical activity.” (Editor’s Note: The ACR offers free patient education fact sheets on rheumatoid arthritis, osteoarthritis, and exercise and arthritis that can be downloaded at www.rheumatology.org/public.)
Dr. Rose and other fall prevention experts say there are three key elements in any fall prevention program. They include assessment (including an environmental assessment of the home for an at-risk patient and pharmacy assessment/medication changes), patient education, and physical exercise. There are no specific guidelines for fall prevention in patients with rheumatic disease, but general recommendations for all patients at increased risk for falls can be adapted by rheumatologists. For patients with rheumatoid disease, exercise activities should focus on balance and mobility, says Dr. Rose. However, she says that all patients with RA or OA should exercise regardless of their degree of risk. Gail Davis, RN, EdD, professor of nursing Texas Women’s University School of Nursing in Denton and a member of the TR editorial board, says, “An exercise program for RA and OA patients should maintain and improve mobility and flexibility and improve strength.”
Dr. Davis says there are a number of outlying factors that can lead to higher risk including vision impairment, cognitive impairment, and drug reaction/interaction. The best approach, say Drs. Davis and Rose, is to understand general evidence-based recommendations for fall prevention risk and individualize a prevention plan for each patient. “This approach is time consuming at first, but it is proven to decrease risk in the long term,” says Dr. Davis. She recommends a multidisciplinary approach. A nurse practitioner working with the rheumatologist can do the initial clinical assessment with the patient. A pharmacist should then be asked to determine the possible impact of polypharmacy, depending on which medications the patient is taking. Referral to rehabilitation services with particular emphasis on physical therapy is the next step, says Dr. Davis. An occupational therapist will conduct a home visit to determine environmental risks for falling, such as poor lighting and loose carpeting and will make recommendations about equipping the home with assistive devices, such as hand rails in the bathroom and stairways and a raised toilet seat.
Studies are demonstrating the success of fall prevention programs in senior centers and group exercise (including Tai Chi) programs. Current research includes a study of the effectiveness of a fall prevention program delivered by community pharmacists, a study of the impact of the fear of falling and patient willingness to actively engage in fall prevention activities such as exercise, and studies on the use of hip protectors among older adults.
For patients with rheumatoid disease, exercise activities should focus on balance and mobility.
Evidence-based Strategies
Rheumatologists should first determine what assessment scale to use to measure fall risk for the RA/OA patient. Dr. Rose and her colleagues developed the Fullerton Advanced Balance Scale (FAB). It includes 10 measurements developed to assess multiple dimensions of balance such as sensory and motor impairments. It is most appropriate for higher-functioning, community-dwelling older adults, says Dr. Rose. The Berg Balance Scale and Timed Up and Go Test are more appropriate for lower-functioning patients. The Berg scale includes 14 items, such as sitting and standing in different positions and transfers. Both the FAB and Berg scale have been studied to determine effectiveness. Published results for the use of FAB in older, higher-functioning adults state, “A practitioner can be confident in more than seven of 10 cases that an older adult who scores 25 or lower is at high risk for falls and in need of immediate attention.”1 A review of 17 studies on functional balance test published in 2007 says, “The Berg Balance Scale and Timed up and Go Test have published reliability and validity.”2
The Centers for Disease Control and Prevention (CDC) has supported a number of grants through a partnership with the Administration on Aging (AoA) that focus on models of fall prevention programs. Ten states have implemented the Matter of Balance program, a small-group model that includes eight two-hour sessions. It is designed to reduce fear, increase self-efficacy and a sense of control in relation to fall risk, and increase physical and social activity. Exercises include foot circles to improve ankle joint strength and range of motion, seated knee raises to improve hip stability and range of motion, toe stands, and alternating marching steps to improve balance and physical endurance.3
The CDC also reports on the Otago Exercise Program, a home-based program done by a physical therapist or nurse who visits the patient four times over a two-month period. This program was tested in four randomized controlled trials and one controlled multicenter trial with results showing a 35% reduction in falls rates. The exercises are tailored for muscle strengthening and balance of increasing difficulty, depending on the patient, and also include walking. Tai Chi is an exercise that is growing in popularity, say Drs. Rose and Davis. It works best in patients who are at low risk of falling. Dr. Rose cautions that Tai Chi should be modified for patients with rheumatoid disease. Researchers at the Oregon Research Institute led by Fuzhong Li, PhD, recently studied the effectiveness of a six-month, small-group program of Tai Chi in RA/OA patients. Participants had a 55% decrease in falls.4 The CDC also funded a study led by Li and colleagues to determine the effectiveness of Tai Chi taught in community senior centers by nonmedical instructors.5 Participants improved health outcome measures, including balance and fall risk reduction, and increased functional independence.
Another option considered for fall prevention is the hip protector. “Fall protectors are one of several fall management tools, but are a hard sell for independent, community-dwelling patients, especially women,” says Dr. Rose. Their biggest benefit is increasing confidence in patients, she says. Research on hip protectors is limited. A CDC-funded study at the University of North Carolina in 2004 evaluated patient views about wearing a hip protector and found that patients felt the best reason to wear one was increased protection from a fall-related injury.6 A study of the effectiveness of using hip protectors in the nursing home setting found no protective effect on the risk of hip fracture.7
Terry Hartnett is a medical journalist based in Pittsburgh.
References
- Hernandez D, Rose DJ. Predicting which older adults will or will not fall using the Fullerton Advanced Balance Scale. Arch Phys Med Rehabil. 2008;89:2309-2315.
- Langley FA, Mackintosh SFH. Functional balance assessment of older community dwelling adults: A systematic review of the literature. The Internet Journal of Allied Health Sciences and Practices. 2007;5(4).
- A matter of balance: Managing concerns about falls. Available online at www.mainehealth.org/mh_body.cfm?id=432. Accessed January 23, 2009.
- Li F, Harmer P, et al. Tai Chi and fall reduction in older adults: A randomized controlled trial. J Gerontol. 2005;60A:187-194.
- Li F, Harmer P, Glasgow R, et al. Translation of an effective Tai Chi intervention into a community-based falls prevention program. Am J Public Health. 2008;98:1195-1198.
- Blalock SJ, Demby KB, et al. Seniors’ perceptions of using hip protectors to reduce hip fracture risk. JAGS. 2008; 56:1773.
- Kiel DP, Magaziner J, et al. Efficacy of a hip protector to prevent hip fracture in nursing home residents. JAMA. 2007; 298:413-422.
