Archive for fall prevention
Josh White, DPM, CPed
One out of three adults age 65 and older fall each year. Falls are a silent killer that most podiatrists simply don’t think much about addressing. Given the scale of the problem and the prevalence of risk factors, developing a specialty in fall prevention presents podiatrists with an opportunity that can significantly benefit their patients and their practice.
Conditions commonly seen by podiatrists and associated with increased risk for falling include:
- Foot pain
- Ankle weakness
- Limited ankle motion
- Postural instability
- Loss of proprioception
- Inappropriate shoe gear
Other risk factors podiatrists should be cognizant of include: dizziness, history of falls or near falls, peripheral neuropathy, impaired balance and drug interactions. If any of these conditions are determined, a more comprehensive fall risk assessment is indicated. See the sample podiatric fall risk evaluation form.
Balance and walking speed gradually decline with age. This is attributable to decreased muscle mass and is exacerbated by reduced activity level. Weakening of the anterior tibialis muscle decreases the body’s ability to maintain balance and may affect the timing of toe clearance during the swing phase of gait. Tripping can result from the toe catching on the floor. Postural sway relates to the constant displacement and correction of the body’s center of gravity over it’s base of support. Decreased muscle strength, particularly with decreased sensation can lead to increased postural sway and increase one’s risk for falling.
No assistive device is as effective at decreasing the likelihood of falls as a walker. Patients though are often resistant to accepting such a device or a cane. Unfortunately, the impetus to use a canes or walker often comes only after a fall occurs. Ankle foot orthoses improve stability by reducing postural sway, increasing sensorimotor feedback and thus improving proprioception. AFOs are only effective when worn and pose patient compliance issues relative to ease of use, impact on shoes that can be worn, comfort and appearance. Fortunately, improved AFO designs fit more easily into shoes, are lightweight, offer ease of closure and still address risk factors that can contribute to increased risk for falling.
Medicare policy makes clear that patients documented to have orthopedic risk factors for falls are covered for custom AFO’s. The Medicare LCD states that to be covered, an item must “be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member”. The Medicare Benefit Policy Manual states that appliances are covered when “used for the purpose of supporting a weak or deformed body member or restricting or eliminating motion in a diseased or injured part of the body.” If biomechanical examination determines any of the following diagnoses to be present, clinical indications demonstrating medical necessity are met:
- Muscle weakness (728.87)
- Ataxia, muscular incoordination (781.3)
- Gait abnormality/ staggering, ataxic (781.2)
- Osteoarthritis, localized primary ankle & foot (715.17)
- Arthropathy, unspecified, ankle and foot (716.97)
- Pain in joint, ankle, foot (719.47)
- Instability of joint, ankle & foot (718.87)
- Dropfoot (736.79)
- Hemiplegia (438.20)
Fall prevention requires a comprehensive approach to care of which custom AFOs may be one component. Based on podiatric fall risk assessment, the podiatrist should consider prescription of primary and ancillary services. Such services and conditions that each may address include:
Physical / Occupational Therapy :
- history of falls
- sensory deficits
- muscle weakness
- poor balance
- vestibular abnormalities
- medication interactions
- history of seizures
- history of hypotension
Home Health Care
- difficulty leaving the home
- Muscle weakness
- hearing loss
- vision loss
By providing appropriate intervention, podiatrists can assume a leading role in a multidisciplinary approach to care.
There are some basic steps that podiatrists can take to develop a fall prevention program:
- Create awareness within ones’s practice regarding the risk of falls and that the office is committed to offering appropriate preventative care. Consider informational brochures and office posters.
- Speak to community groups about the role of intervention to reduce patient risk.
- Network with other physicians and specialists including physical therapists, occupational therapists and home healthcare workers to promote a team approach to care.
- Perform fall risk assessment and consider use of balance AFO if appropriate risk factors are determined.
There is no simple fall prevention strategy that will work for all patients. As falls result from of a complex interaction of intrinsic and extrinsic risk factors, interventions require a multi-faceted approach. A strong fall prevention strategy that encompasses a number of interventions and targets multiple risk factors is more likely to be successful.
Research studies carried out among the elderly through the years have shown significantly more falls resulting in serious injuries, due to problems with balance. Implementing balance testing and providing foot orthoses’s for elderly patients could prove to potentially decrease the amount of falls and injuries associative with them.
With the inclusion of specific balance testing such as the ‘tandem stance test,’ and the ‘tandem gait test’ specialists in orthopedic care can provide a better means of assisting their elderly patients with improving balance, thus minimizing serious bodily injury from falls. Dr. Michael T. Gross said that, “clinicians should consider asking older patients about their balance, and have them perform simple one leg balance tests.” This alone will help in determining specific balance problems, and earlier evaluations for the possible need of foot otrhoses’s, which could prevent accidental falls before they happen. The varied participant studies have proven that foot orthoses’s which are designed for each individual patient’s needs work to improve their own balance defects.
While the studies have been small thus far, and the results “preliminary,” Dr. Gross says that, “It’s important to note that we examined and addressed individual foot issues.” Therefore, these basic tests are detrimental in patient care, because they allow for individual structural differences in gait and balance for each patient’s orthoses design. Not every patient needs corrective features, or something like arch support, and these basic tests can help determine what will provide the most improvement for each and every patient orthopedic specialists have come in.
To read the full article you can access it here: http://www.lowerextremityreview.com/news/in-the-moment-footcare/enhancing-balance
Podiatrists can improve patients’ lives and help reduce the overall cost of healthcare by implementing a comprehensive fall prevention program. SafeStep offers ample opportunity and encourages podiatrists to learn more about how to start one and to not be frightened by alerts and postings that imply an assumption of great risk by utilizing custom AFOs as a part of treatment.
“Comparative Billing Reports” from Medicare demonstrate that on average, DPMs dispense 0.7 L1940 devices, per podiatrist, PER YEAR! There is not a problem of custom AFO over utilization but most definitely one of underutilization.
Medicare policy is clear that patients documented to have orthopedic risk factors for falls are covered for custom AFO’s including the Moore Balance Brace. Recent posts intended to discourage AFO utilization serve as reminders of the importance of following established treatment protocols and of Medicare documentation requirements.
The Medicare LCD states that to be covered, an item must “be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member”.
The Medicare Benefit Policy Manual states that appliances are covered when “used for the purpose of supporting a weak or deformed body member or restricting or eliminating motion in a diseased or injured part of the body.”
If biomechanical examination determines any of the following diagnoses to be present, clinical indications demonstrating medical necessity are met and that if dispensing custom AFO’s, podiatrists can be confident of satisfying Medicare guidelines:
Muscle weakness (728.87)
Ataxia, muscular incoordination (781.3)
Gait abnormality/ staggering, ataxic (781.2)
Osteoarthritis, localized primary ankle & foot (715.17)
Arthropathy, unspecified, ankle and foot (716.97)
Pain in joint, ankle, foot (719.47)
Instability of joint, ankle & foot (718.87)
SafeStep will continue to be a strong supporter of podiatrists’ role in fall prevention and embraces the opportunity to dispense custom AFO’s as a legitimate means of treatment.
For seniors, complications from a fall, even including death, is all too real. Without some type of brace, such as the Moore Balance Brace, these senior increase their risk of falling and causing themselves injury.
What does a fitted brace give? It gives stability and mobility through increased balance and usability. While nothing new for us in the podiatry world, not all patients understand these benefits.
To help promote this understand, I found a great write-up about using leg braces for increased mobility in senior citizens on Your4State.com
Along with an easy to follow video, I believe this type of educational content will help patients understand the need for assistance, such as the Moore Balance Brace.
To read the entire article, click the link below:
Last week, on the SafeStep forum, we had a question answered by Jonathan Moore and this week, we are proud to present a tutorial he wrote for the Moore Balance Brace.
With this summary, Jonathan gives us everything from presenting the MBB to patients to helping your patients walk with the brace.
If you have other questions not addressed in this FAQ, please contact us to have Jonathan answer your specific question on the Moore Balance Brace.
Moore Balance Brace Tutorial
Presenting the MBB to Your Patients
- When presenting the MBB to your patients, try to have a brochure ready to give to the patient so they can look, visualize and read the brochure as you discuss the idea with them. Have one too for any family in the treatment room.
- I usually start with the patient by asking them to read with me and answer the questions that are on the back page of the brochure. The section is entitled: Do You Have a Balance Problem?
- Have you fallen in the past?
- Do you often slip, trip or have near falls?
- Do you stumble or shuffle when you walk?
- Do you have to touch or hold on to the well or furniture while walking?
- Do your legs or ankles feel weak or unsteady?
After asking these questions, most patients will say “yes…that is me!”
- After reviewing the brochure and showing the patient the brace, I emphasize 3 vital point that the patient will need to know in order to commit to trying the MBB.
- Ankle foot orthoses are extremely lightweight. In fact they are not much heavier than a cell phone. This point is critical, so don’t forget to emphasize this. If you don’t have a sample of the MBB, hand them your cell phone for them to see how light they are.
- Ankle foot orthoses ARE covered by Medicare. Medicare would much rather pay for these ankle-foot balance supports than pay the many thousands for a fall and hospital stay.
- Ankle foot orthoses can (and have been shown in studies) to be able to reduce the risk of falling up to 30-60%. Despite this, I emphasize that if they improved balance enough to prevent a SINGLE fall, they are worth it.
- ***Very importantly: DO NOT USE THE TERM “BRACE” or “AFO” . The term “AFO” will NOT be understood by patient, and “brace” carries a very negative connotation. Instead, I use the terms “fall prevention device”, “foot and ankle support”, or “balance technology”.
- Don’t forget to tell the patient how important physical therapy or some exercise regimen is to improving balance and stability.
- Presentation is everything to getting a senior to comply with your plan, but the most effective means to demonstrate to the patient how “at-risk” they are is to show them the results of your Fall Assessment. Many of my patients have scores of 15 or 20. Far above the 10 mark, which indicates high risk.
- Finally, if you are seeing a senior presenting to you on their own, ask that they bring a family member, or spouse to hear your presentation (even if the patient has rejected the idea). Often times, care providers and family will be the most motivated to implement a plan to help reduce the risk of a fall.
Shoeing the MBB
- The right shoe is critical for the success of the MBB. Make sure you offer the right shoe or insist that the patient use the MBB’s in a “Balance” shoe in order to maximize the benefit of the devices. I highly recommend you have a Shoe Recommendation List that includes a category called “Fall Prevention Shoes”.
Among my favorites are; New Balance 811, New Balance 927, Pedor 800, 801 or the Pedor 901, 902, and the Orthofeet 910 or 916, and lastly the Brooks Addiction Walker or the Brooks Beast/Ariel
***Avoid any shoe that has too thick of a midsole.
***Avoid any “Shape Up” style rocker bottom shoe
***Velcro is ALWAYS preferred over Lace.
- Order the shoes or carry a run of shoes that will accommodate most of your MBB patients so that patients don’t have to wait an additional period of time after the MBB’s come in.
- Though, the MBB will fit into most shoes, you still need to educate your patients how important it is to wear the right shoe with the MBB in order to maximize stability.
- DO NOT PUT THE MBB ON TOP OF A SHOE INSOLE or OROTHOTIC: This may reduce the stabilizing impact of the MBB in the shoe. The MBB is posted extrinsically in the heel to sit flat onto a surface. Preferably a surface that is not too cushioned or thick. I use either a thin Spenco insole (flat) or a spacer insole that often comes with Diabetic Shoes. You do not want the patients forefoot (past the MBB) to be on the bottom of the shoe, but keep in mind that the patients forefoot needs to remain as close to the bottom of the shoe as possible to increase stability.
DONNING THE MBB
- Open the MBB and put the device into the shoe after expanding the shoe to its fullest in order to accommodate the foot and the MBB. Velcro shoes make this much easier.
- Don’t forget to have a thin spacer in the place of the shoe insole.
- Make sure the MBB is snug against the back of the shoe.
- While the patient sits, have them point their toe and slide their foot into the shoe and MBB.
- Help them by making sure their foot is directly below their knee and not out.
- Show the patient how to grab the back of Upper MBB to aid them sliding their foot into both the shoe and the MBB.
- If the foot doesn’t slide smoothly into the shoe/MBB then you need to re-evaluate the size and width of the shoe. If the patient struggles sliding their foot into the MBB and shoe, then they are more likely to be NON compliant with their use.
- After the patient slides their foot into the MBB/shoe them how to tuck the tongue of the MBB under the outside Velcro piece in order to pull straps over and across the ankle.
- Allow the patient to adjust the tightness of the straps, but do not let the patient allow the straps to be too tight nor too lose.
10. After fastening the 2 velcro straps, the shoes should be firmly latched and then the patient will be ready to walk.
Walking for the first time with the MBB
- Always encourage the patient to continue the use of their cane or walker. DO NOT EVER DISCONTINUE ankle foot orthoses after they start using the MBB.
- Ask the patient if the MBB’s hurt, rub or cause any discomfort. If they do, check the shoe to make sure of the right fit.
- Also, make sure the straps of the MBB are not too tight. This is the most common complaint upon first walking with the MBBs.
- I always encourage a “break in” period, but I don’t discourage patients if they want to use the MBB’s continually if they feel good and feel improved stability. ***At least 80% of my MBB patients relate that they didn’t feel as though they needed a “break-in” as the braces felt good and supportive.
- Encourage the patient to use the MBB’s every day, but DO NOT mandate that they have to wear the MBB’s (at least initially) all of the time.
This can often frighten the patient and make them antagonistic toward the devices.
*** Most patients will use the MBB more consistently as they get used to them and have time to realize their effectiveness.
Recently, on the SafeStep Forum, we had a question on Moore Balance Brace answered by the AFOs developer, Dr.. Jonathan Moore.
To view Dr. Moore’s detailed response to this question, check out the forum post here:
While you’re there, be sure to check out the SafeStep Forum and sign-up to engage in conversation with your peers in the industry.