Easy Does It
By Richard Sabel, MA, MPH, OTR, GCFP; Katherine Balton, BA, OTS, CYT; Isaura Reyes; Krista Rozas; and Brooke Serebryansky
Today’s Geriatric Medicine
Vol. 14 No. 1 P. 14
An Occupational Therapy–Based Fall Prevention Program
Falls are one of the leading causes of injury in community-dwelling older adults. These incidents can have potentially serious consequences and contribute significantly to morbidity and mortality rates for this cohort.1 As this population continues to grow, fall-related injuries will have an increasing impact on the US health care system. Many normal physiologic changes associated with aging contribute to increased fall risk; these include changes in vision, cognition, balance, muscle strength, flexibility, and proprioception.2 While the normal process of aging cannot be avoided, targeted interventions provided through fall prevention programs can mitigate some of the factors that contribute to fall risk.
The Occupational Therapy Approach
Occupational therapy is a holistic approach to intervention based on science and evidence-based practice that aims to develop, restore, and maintain participation in meaningful activities or occupations. Occupational therapists work with individuals across the lifespan, adapting the environment and/or task to meet their needs and enable engagement. Instead of simply focusing on deficits or the client’s diagnosis, occupational therapists maximize their clients’ function based on their abilities and strengths. Occupational therapy interventions help clients reengage in meaningful occupations and enhance overall quality of life.
Tenets of occupational therapy practice are captured throughout the book Being Mortal: Medicine and What Matters in the End by Atul Gawande, MD, MPH. In one chapter, he describes the chief geriatrician’s interaction with a client. She had a complex medical history: lower back pain, arthritis, prior bilateral knee replacements, high blood pressure, glaucoma, incontinence, prior colon cancer, and a potentially metastatic nodule in her lung.3 Rather than focusing his attention on these conditions, he saw a potential fall as detrimental to her health. To better understand what was important to her, he asked about her daily life in great detail. This revealed that she was active throughout the day, mentally sharp, and relatively independent. Much of the exam was spent examining her feet, as it can be an effective, quick way to assess movement and hygiene. He observed unclipped nails, sores between the toes, and calluses. His examination further revealed additional deficits in self-care skills as a result of decreased mobility, the patient’s use of multiple medications that could lead to dizziness, and her low-calorie diet insufficient for maintaining muscle strength. For this patient, and many like her, the greatest threat to her independence and quality of life was not her medical conditions but falling and “losing what she had.” Gawande emphasizes the importance of focusing on well-being instead of the disease process, which is foundational to occupational therapy practice.
Occupational therapists are invaluable resources for addressing fall prevention among community-dwelling older adults. With fall prevention being such a multifaceted issue, occupational therapists possess the skills to evaluate and address how individuals, and their daily activities, roles, and routines, as well as their environments, influence their ability to navigate independently and safely. Aligning our efforts with what is most important to the client, with pertinent modifications and adaptations that facilitate their ability to engage in meaningful activities, is key to the profession, serving the unique needs of each client while mitigating health care costs.4
Fall Prevention Strategies
An effective fall prevention program addresses physical, behavioral, and environmental domains. Research demonstrates that any physical practice is helpful in addressing normal changes of aging. Modalities such as yoga, tai chi, and the Feldenkrais Method are particularly beneficial because they all include slow, controlled, full-body movement with a mindfulness component (being aware in the moment) that increases body awareness. Body awareness, influenced by proprioceptive processing, is the understanding of the position of one’s body in space. Receptors in muscles and joint capsules provide this sensory input that allows us to safely navigate our environment. As people feel and understand their bodies more clearly, they’re better able to engage in functional activities during everyday occupations.
The mind-body component of yoga provides this modality with the potential to be more therapeutic than traditional forms of exercise. When the mind is focused on what the body is doing and feeling, one's sense of proprioception increases along with body awareness.5 A study of yoga’s effect on falls found the frequency of falls to be reduced significantly after yoga intervention.6 Tai chi is a traditional practice consisting of slow weight-shifting movements that require an increased level of concentration and attention; this practice is associated with feelings of physical and psychological relaxation that facilitate resilience in stressful situations.7 Evidence supports the use of tai chi as an effective modality in reducing falls in older adults through the improvement of balance-control and flexibility.8 The Feldenkrais Method is another practice that ties together the concept of body awareness through the use of gentle movement and directed attention. Research into the practice has demonstrated a significant decrease in fear of falling and increase in balance and mobility offsetting age-related declines in movement in the older adult population.9 This practice aims to discover efficient movement patterns and to generalize these to everyday life.
In addition to physical modalities, various environmental and behavioral interventions have been studied as a means of reducing falls. Behavioral interventions are centered around client education. Common topics include footwear risk, orthostatic hypotension, and energy conservation strategies.10 Clients are educated about modifying their behavior (eg, rushing to the phone or bathroom) and are encouraged to be less impulsive and to make transitional movements such as going from sitting to standing more slowly to minimize fall risk. Environmental interventions include home assessments that address hazards such as poorly placed electrical cords, loose stair rails, and cluttered walkways. Assistive devices may also be introduced, particularly equipment in the bathroom such as grab bars and nonskid mats. The combination of physical, behavioral, and environmental strategies empowers older adults to take an active role in their safety at home and in the community.
The Easy Does It Fall Prevention Program
Easy Does It is a 10-week fall prevention program led by a licensed occupational therapist. This program emphasizes the functional applications of slow, controlled, full-body movement patterns found in yoga, tai chi, and the Feldenkrais Method. By relating these traditions to everyday occupations, the program enables participants to directly apply these movement strategies to their daily routines. Integrated full-body movement, which disperses effort throughout the body, provides additional benefits of joint protection and energy conservation. For example, tai chi forms feature slightly flexed knees and hips and a wider base of support, which can be relied on in activities such as riding the subway or waiting in line at the grocery store. Rather than using their arms in isolation, participants learn to emphasize trunk and pelvic rotation, also common in tai chi, while performing activities such as opening a heavy door, ironing, or pulling a suitcase off a conveyor belt.
Components of the Feldenkrais Method bring participants’ awareness to the importance of pelvic mobility and its impact on everyday activities. Participants are led through the example of donning a shoe. When seated with the pelvis tilted forward (anterior pelvic tilt), they observe that it’s more challenging to lift their legs and reach their feet. Tilting the pelvis backwards (posterior pelvic tilt) makes the movement easier, more comfortable, and stable. While tilting the pelvis backwards facilitates donning a shoe, it can make other activities, such as reaching across the dinner table or standing, more difficult. For these activities, rolling the pelvis forward facilitates easeful, stable movement. Helping older adults connect the movement patterns characteristic of yoga, tai chi, and the Feldenkrais Method to movements used in the performance of everyday activities increases participation while decreasing the fear of falling.
Over several years, a quality assurance project was conducted by occupational therapy students at State University of New York Downstate Health Sciences University to evaluate the efficacy of The Easy Does It Fall Prevention Program. Quantitative data were obtained through the Activities-Specific Balance Confidence scale, Timed Up and Go Dual Task assessment, and two sets of Likert scale questions. Qualitative data were collected through participant interviews. Upon reviewing findings from the last two years, emerging trends indicate decreased fear of falling and improved engagement in functional activities after participation in the 10-week program.
For one Likert scale, participants were asked to identify two functional activities influenced by their fear of falling and rate their performance and satisfaction before and after the program. The average post score was higher than the average pre score for all participants when analyzing these results. Additionally, at the end of each session participants rated their overall sense of body awareness, including their sense of stability while standing, walking, and reaching. Their responses indicated improvements in awareness and stability over the course of the program.
Qualitative data collected through participant interviews proved successful in highlighting the physical, behavioral, and environmental domains addressed by the program, with multiple participants discussing changes that fall within these parameters. Participants described experiencing physical changes as a result of program participation. Some examples of these changes include an increase in range of motion, strength, and overall flexibility. Participants expressed being more aware of their bodies after participating in the program, acknowledging a behavioral change. They implemented techniques such as standing with their knees a little bent, or “soft,” and used more of their body rather than one isolated area to engage in functional activities. According to one participant, “[When] reaching for the canister, I don't just reach with my arm; I turn my body and I reach with both hands.” Another emphasized awareness of her knees, saying, “I’m more aware of what I’m doing, like I’m really remembering my knees, ’cause I didn’t realize I was locking them.” A member of the program explained that she had a tendency to walk fast, however, after the program she became more cautious of controlling her speed while walking, thus becoming more aware of her foot placement against the floor. Participants also noticed a difference in the way that they sit since participating in the program. One participant stated that she is mindful not to “plop” into her seat when traveling on the bus.
Most of the participants interviewed discussed a mild to severe fear of falling before beginning the program. Since completing the program, they expressed a decline in this fear. According to one participant, “Now I don't think of it as much. I still do think of it, but I try to just walk with a little bit more assurance and propel myself forward.” Changes in awareness of their environments was another theme that emerged from the interviews. One participant removed loose wires and dangerously placed items around her home. Ultimately, participants’ fear of falling decreased while their confidence and body awareness improved when performing functional activities. A key marker of the program’s occupational therapy influence was the participants’ ability to apply the information learned to their everyday lives.
Change is difficult. It unsettles engrained habits, which can impede compliance. This is a key challenge all health professionals face when recommending lifestyle changes. To address this issue, participants were asked during the first session to clasp their hands and notice which index finger was on top, the right or left. Next, without looking, everyone was asked to clasp their hands again, but this time change the grasp, so opposite index finger was on top. This hand clasp took more time as participants had to think about the movement and to most it felt unnatural. Some could not do it. This experience illustrated that change, although initially unsettling, is possible and that with time, this new way will feel familiar and right. Whenever someone in the group became frustrated or stuck, someone would say, “Remember the hand clasp.” The participant would smile, and the group continued.
The ideas shared in this article can easily be adapted to ongoing fall prevention programs. The key components are: 1) regardless of the physical exercises, relate the movements, when possible, to everyday activities; 2) provide a home safety checklist with a follow-up discussion on what people have discovered; 3) during breaks, talk about strategies for modifying behaviors that get us into trouble, such as rushing to pick up the phone or standing on rickety stools; and 4) have participants identify two activities that have been negatively influenced by their fear of falling. After a set period of time, have them reassess their level of confidence while engaging in those activities.
By addressing physical, behavioral, and environmental variables, the Easy Does It Fall Prevention Program demonstrates the value of a multifaceted approach. The program incorporates the basic principles of occupational therapy. This approach empowers participants to directly apply strategies learned in the program to their daily roles and routines, thus increasing engagement. Individuals who participated in the program noted improvements in their balance and body awareness, as well as a decreased fear of falling.
Advocacy for the connection between movement and function, well understood by occupational therapists, can support the safety and well-being of community-dwelling older adults and reduce their risk of falls. The involvement and collaboration of various health care providers with occupational therapists is integral to a complete fall prevention initiative. Providers who work with this population and wish to support their safety and well-being can implement the principles of the Easy Does It Program within their own fall prevention initiatives.
— Richard Sabel, MA, MPH, OTR, GCFP, is a clinical assistant professor at SUNY Downstate Medical Center’s Occupational Therapy Program and the educational director of East West Rehab.
— Katherine D. Balton, BA, OTS, CYT, is a certified yoga instructor and occupational therapy student at SUNY Downstate Medical Center's Occupational Therapy Program. She looks forward to working with both adults and children as a licensed occupational therapist in the near future.
— Krista Rozas has a BA in psychology and is an occupational therapy student at SUNY Downstate Medical Center's Occupational Therapy Program.
— Isaura Reyes has a BA in psychology and is an occupational therapy student at SUNY Downstate Medical Center's Occupational Therapy Program.
— Brooke Serebryansky has a BS in nutrition and exercise science and is an occupational therapy student at SUNY Downstate Medical Center's Occupational Therapy Program.
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