By Frederick Carrick, D.C., Ph.D., FACCN
he majority of balance disorder patients are never identified until a fall occurs
and the majority of patients that will fall have no symptoms that would alert
them or their healthcare provider to this probability. The Joint Commission
on Accreditation of Healthcare Organizations (JCAHO) has identified fall reduction
as a priority in 2005. In accordance with other accredited health agencies and
the direction of JCAHO the American Chiropractic Neurology Board (ACNB) has
developed a certification program in Vestibular Rehabilitation.
Fall prevention is a necessary part of all healthcare provider practices and
prevention of falls equates to saving lives. Most fall prevention programs are
central to a non-pharmaceutical approach that is in concert with the practice
of chiropractic. Falls are not only a problem of the elderly. While age was
shown not to be a significant predictor of serious fall related injury1,
falls are the dominating injury mechanism among the elderly2
and are a leading cause of morbidity and mortality among children3
as well as a common cause of serious infant injuries4. The
five leading mechanisms of injury death in the USA are motor vehicle traffic,
firearm, poisoning, falls and suffocation, accounting for 78 percent of all
injury deaths5. Falls are a leading cause of morbidity and
mortality in the construction trades and are responsible for a significant burden
of work-related injury costs6. Unintentional home injuries,
especially falls, are a major problem in the United States costing U.S. society
at least $217 billion in 19987.
This problem is not limited to the USA. The projected health system costs of
falls in older Australian adults will increase to $181 million in 2021 with
a substantial economic burden to the health services of Australia8.
Falling is an increasing hazard for older people, especially for women, for
people living in rural areas and for those with different mental and physical
disabilities9. Falls among elderly persons create immense
social problems because of their association with physical decline, serious
psychosocial consequences, negative impact on the quality of life, markedly
reduced survival and high costs to the public health service10.
Falls in institutional care predict poor survival and falls must be prevented11.
The age-related decreases in vestibular, visual, auditory and somatosensation
in normal older people are weakly correlated with changes in gait and balance
while white matter hyperintensities on magnetic resonance imaging are more highly
correlated, but all variables together account for only about 29 percent of
the measured change in gait and balance12. The recovery of
balance is slower and less efficient in balance-impaired elderly persons when
simultaneously performing a cognitive task, whereas the ability of healthy elderly
individuals to recover is not influenced by concurrent task demands suggesting
that dual-task performance may contribute to postural instability and falls
in balance-impaired elderly individuals13. For example, there
is a possibility of increased falls and pedestrian accident risk in older individuals
involved in dual task situations such as road crossing14.
Falls among elderly persons remain a difficult problem with few easy solutions15.
Falls occurring among older adults have serious physical, psychological and
social consequences, reinforcing the need for fall prevention, in order to ensure
greater quality of life, autonomy and independence for the elderly16.
Community physicians appear to underdetect falls and gait disorders, while detected
falls often receive inadequate evaluation, leading to a paucity of recommendations
and treatments17. There is compelling evidence from public
health research to support health promotion policy for making societal investments
in community falls-prevention programs18 and there is an
urgent need to develop and implement preventive measures as well as multidisciplinary
strategies to identify, assess and target high-risk persons for falling19.
Patients that might fall when their eyes are closed while standing on a perturbed
surface may be identified with posturography in order to establish early intervention
programs and to develop effective strategies for fall prevention and treatment20.
Balance can be assessed by computerized dynamic posturography, which determines
the subject’s response to reduced or altered visual and somatosensory
orientation cues21.
Posturography is a well tolerated screening test which directly measures increased
sway in patients and may be used as a more direct screen for risk of falls than
EMG22. On average, the velocity of sway (particularly in
the anterior-posterior direction) is higher in older subjects who complain of
imbalance compared with age-matched controls, and the difference is greater
with dynamic posturography than with static posturography23.
Computer dynamic posturography is a more sensitive test for identifying patients
who have fallen, than electronystagmography studies24. For
many patients with dizziness and/or balance dysfunctions, posturography can
provide additional information to that obtained with electronystagmography,
especially those patients with normal or borderline normal electronystagmography
findings25.
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Dynamic balance measures obtained with platform posturography are generally
stable across multiple evaluations26 and therefore might
be used to measure change in patient stability after a variety of treatments.
A comprehensive assessment of postural stability (CAPS-Vestibular Technologies,
Cheyenne, WY) computer dynamic posturography system has been validated to demonstrate
stability and a probability of falling in the eyes closed perturbed surface
test27 and can be utilized to collect stability scores. It
is frustrating for clinicians to validate the need for chiropractic treatment
when there is often no objective membership. The doctor is usually dependant
upon his/her subjective assessment of the patient’s situation. The CAPS
test can provide objective data that will allow the chiropractor to identify
those patients at risk of falling and to also document changes as a consequence
of chiropractic intervention.
Training in Vestibular Rehabilititation empowers chiropractors to be able to
serve his/her community better. The use of screening tools such as the CAPS
test will allow the doctor to identify those individuals in need of treatment
that would not normally present to a chiropractor. Chiropractors who are trained
in Vestibular Rehabilitation will have the tools necessary to establish themselves
as experts in the discipline in their community. As all health professionals
will be required to include objective fall prevention strategies in 2005, it
is imperative that doctors of chiropractic become fluent in these areas. The
service to humankind that is possible as a consequence of graduate education
in fall prevention is immense. There are not enough trained professionals to
address the needs of our society in regards to fall prevention.
About the Author:
Frederick R. Carrick, D.C., Ph.D., is the professor emeritus of neurology at
Parker College of Chiropractic and a distinguished postgraduate professor of
clinical neurology at Logan College of Chiropractic. Dr. Carrick is also the
president of the ACA Council on Neurology.
References
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