Prevention of falls in the elderly--a key role for the falls clinic

Falls are a major health problem among elderly people, because of the incidence and because of the consequences. Current practice commonly focuses on the injury with little attention of the underlying cause, the risk factors for a new fall and the possibilities for future prevention. Most of the falls are a result of multiple risk factors. Several of this risk factors are potentially modifiable. The Dutch Falls Prevention Collaboration have made a protocol to assist health care professionals at a standardised and evidence based way with their assessment of fall risk. With the risk factors identified in the assessment it is possible to make an individual multifactorial fall prevention program. Such an intervention can give a significant reduction of falls in the elderly. The protocol is presented in this article.     

Wrist impact velocities are smaller in forward falls than backward falls from standing

The wrist is a common fracture site for both young and older adults. The purpose of this study was to compare wrist kinematics in backward and forward falls with different fall protective responses. We carried out within-subject comparison of impact velocities and maximum velocities during descent of the distal radius among three different fall configurations: (a) backward falls with knees flexed, (b) backward falls with knees extended and (c) forward falls with knees flexed. We also examined the effect of fall configuration on fall durations, elbow flexion, trunk flexion and forearm angles at impact. Forward falls resulted in smaller impact velocities of the distal radius, longer fall duration, longer braking duration, greater elbow flexion and more horizontal landing position of the forearm compared to backward falls. The distal radius impact velocity during forward falls (1.33 m/s) was significantly lower than in backward falls, and among the backward falls the impact velocity of the flexed knee strategy (2.01 m/s) was significantly lower than the extended knee strategy (2.27 m/s). These impact velocities were significantly reduced from the maximum velocities observed during descent (forward falls=3.57 m/s, backward falls with knee flexed=3.16 m/s, backward falls with knees extended=3.52 m/s). We conclude that (1) smaller impact velocities of the wrists in forward falls could imply a lower fracture risk compared to backward falls, and (2) fall protective responses reduced wrist impact velocities in all fall directions.     

Responses to gait perturbations in stroke survivors who prospectively experienced falls or no falls

Background: Steady-state gait characteristics appear promising as predictors of falls in stroke survivors. However, assessing how stroke survivors respond to actual gait perturbations may result in better fall predictions. We hypothesize that stroke survivors who fall have a diminished ability to adequately adjust gait characteristics after gait is perturbed. This study explored whether gait characteristics of perturbed gait differ between fallers and non fallers. Method: Chronic stroke survivors were recruited by clinical therapy practices. Prospective falls were monitored over a six months follow up period. We used the Gait Real-time Analysis Interactive Lab (GRAIL, Motekforce Link B.V., Amsterdam) to assess gait. First we assessed gait characteristics during steady-state gait and second we examined gait responses after six types of gait perturbations. We assessed base of support gait characteristics and margins of stability in the forward and medio-lateral direction. Findings: Thirty eight stroke survivors complete our gait protocol. Fifteen stroke survivors experienced falls. All six gait perturbations resulted in a significant gait deviation. Forward stability was reduced in the fall group during the second step after a ipsilateral perturbation. Interpretation: Although stability was different between groups during a ipsilateral perturbation, it was caused by a secondary strategy to keep up with the belt speed, therefore, contrary to our hypothesis fallers group of stroke survivors have a preserved ability to cope with external gait perturbations as compared to non fallers. Yet, our sample size was limited and thereby, perhaps minor group differences were not revealed in the present study.     

Rehabilitation after falls and fractures

Falls are one of the most common geriatric problems threatening the independence of older persons. Elderly patients tend to fall more often and have a greater tendency to fracture their bones. Fractures occur particularly in osteoporotic people due to increased bone fragility, resulting in considerable reduction of quality of life, morbidity, and mortality. This article provides information for the rehabilitation of osteoporotic fractures pertaining to the rehabilitation of the fractured patient, based on personal experience and literature. It also outlines a suggested effective and efficient clinical strategy approach for preventing falls in individual patients.     

Biomechanics of reactions to impending falls

Responses of 11 young adult males, initially standing, to support surface forward accelerations of 0.18 g were investigated. In response to the impending falls this stimulus initiated, body segment motions and myoelectric activities in six muscles were measured. These measurements were then input to 9 or 12 segment whole body biomechanical models and the reaction joint torques needed to produce the motions were calculated. Mean relative joint rotations were as large as 92.8 degrees and calculated relative joint angular accelerations as large as 29.7 rad s-2. Mean myoelectric signal latencies in the six muscles monitored ranged from 135 ms at the ankles to 176 ms at the shoulders with intermediate values at intermediate joints. Mean values of calculated maximum joint torques ranged to 70 Nm at the ankles, 82 Nm at the knees, 73 Nm at the hips, and 19 Nm at the shoulders.     

The rise and falls of introns

There has been a lively debate over the evolution of eukaryote introns: at what point in the tree of life did they appear and from where, and what has been their subsequent pattern of loss and gain? A diverse range of recent research papers is relevant to this debate, and it is timely to bring them together. The absence of introns that are not self-splicing in prokaryotes and several other lines of evidence suggest an ancient eukaryotic origin for these introns, and the subsequent gain and loss of introns appears to be an ongoing process in many organisms. Some introns are now functionally important and there have been suggestions that invoke natural selection for the ancient and recent gain of introns, but it is also possible that fixation and loss of introns can occur in the absence of positive selection.     

Protective movements during sideways falls from standing height

To examine the effect of protective movements during sideways falls from standing height (i.e., from the standing position), a two-step study was performed. In the first step, 80 young male and female volunteers freely fell onto a sport-mat. All falls were recorded on videotape, and replayed to analyze movements in response to the falls. Several protective movements were observed; forward flexion and lateral flexion were observed with a particularly high frequency. In the second step, impact velocities of the head and hip were measured by a three-dimensional motion analyzer regarding three types of falls: stiff falls, forward flexion falls and lateral flexion falls. Both types of flexion reduced impact velocities of the head, but not those of the hip. The reduction of the impact velocity on the head correlated with the lowering of the height of the head from the floor.     

The effectiveness of falls clinics in the Netherlands

Recently, two articles are published about the effectiveness of a multifactorial fall prevention programme performed by two falls clinics in the Netherlands. Both studies have shown negative results. The question is if those two studies are representative for the real situation in most falls clinics in the Netherlands. Two important differences are the selection of the patients and the completion of the fall prevention program. It is important to select the patients with the highest fall risk (> or = 2 falls/year and/or > or = 4 fall risk factors) and to provide an active and direct management of the identified fall risk factors to improve the effectiveness of falls clinics.