PATHOLOGY: Implications for the Physical Therapist

PROGNOSIS.

In general, fractures in children heal in 4 to 6 weeks; in adolescents in 6 to 8 weeks; and in adults in 10 to 18 weeks. This process from fracture to full restoration of the bone will take weeks to months, depending on the type of fracture, location, vascular supply, health, and age of the individual. Nonunion or delayed union is more likely to occur in adults and occurs in up to 10% of all fractures (affecting nearly 500,000 people each year in the United States).⁴⁰⁹

Older adults who have suffered a hip fracture have the highest rate of nonunion complications (15% to 30%). These individuals are almost four times more likely to die in the first year after fracture compared with those without fracture. Delay until surgery after hip fracture increases mortality significantly.³¹⁹ Older women (more than 65 years) who survive the first year after a hip fracture may be at increased risk of death up to 5 years after the injury.^207,300

Many people are at high risk for premature death or loss of independence following fracture; mortality after fracture is higher among men than among women.^41,46 Less than 50% of older adults with a hip fracture will regain their prior level of function.⁴⁵⁷ The inability to stand up, sit down, or walk 2 weeks after surgery is the strongest predictor for mortality among older adults with surgically repaired hip fractures.^187,490

A person’s condition before fracture (especially that of older adults with hip fractures) has important prognostic implications. Older adults who fall within 6 months following a hip fracture are more likely to demonstrate poorer balance, slower gait speed, and greater decline in ADL from the prefracture level than those who do not fall.⁴⁵⁷

Healthy functional status contributes to faster recovery time with fewer complications and reduced medical expenses.⁸⁸ Negative predictors for healing include medications such as calcium channel blockers and NSAIDs, renal or vascular insufficiency, smoking, alcoholism, and diabetes mellitus. Treatment can also affect healing via inadequate reduction, poor stabilization and fixation, distraction damage to blood supply, and postoperative infection.

Associated complications such as nerve injury can occur, and it can take up to 12 to 18 months before reinnervation of the motor endplate is complete. Return of function is dependent upon this factor. If there are no signs of improvement by 7 months, spontaneous recovery is unlikely.⁵⁴⁰ Exploratory surgery may be indicated at that time.

27-17 SPECIAL IMPLICATIONS FOR THE THERAPIST

Fracture

PREFERRED PRACTICE PATTERNS

Besides the obvious practice patterns, complications from the fracture or the treatment for the fracture can result in skin, vascular, neurologic, and joint involvement beyond the effects associated with bony injury. In such cases, other corresponding practice patterns may apply. Criteria for fractures of the skull may be best described by the neuromuscular practice patterns.

4G:

Impaired Joint Mobility, Muscle Performance, and Range of Motion Associated with Fracture

4H:

Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated with Joint Arthroplasty

4I:

Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated with Bony or Soft Tissue Surgery

7A:

Primary Prevention/Risk Reduction for Integumentary Disorders

There are excellent resources regarding fractures available for the therapist managing fractures, including special considerations, orthopedic intervention, rehabilitation considerations, precautions, goals, and therapeutic exercise with expected time frames for healing and rehabilitation.^{61,202,259,430,440}

For the older adult, there are many potential consequences of fractures. These include biomechanical, functional, and psychologic effects that can limit function and result in considerable disability. Biomechanical consequences can include anorexia and weight loss, compression of abdominal contents and decreased lung function from kyphotic posture, and the risk of more fractures.

Chronic, debilitating pain and increased dependence on family and friends occur as part of the functional consequences. Often there is a significant decrease in the individual’s ability to perform ADLs because of impaired physical function. These factors combined with depression and anxiety (and for some people, sleep disorders) results in psychologic consequences.⁴⁰⁴ The therapist must remain alert to all of these potential consequences when evaluating each client and planning the best approach to clinical management.

Tobacco use, especially cigarette smoking (both the nicotine and the smoke itself) exposes individuals to toxins that can delay bone healing considerably. Nicotine occupies receptor sites on the stem cells’ surface that are intended for acetylcholine, a chemical that helps nerve cells communicate. Normally, stem cells turn into cartilage-forming cells needed to create the scaffold for callus development over the break.

Nicotine’s effect on stem cells is to cause them to produce too much cartilage while at the same time blocking nerve transmission and delaying or preventing bone healing. Therapists should review the hazards of smoking with clients who have fractures and encourage smoking cessation or reduction. Using nicotine patches or gum immediately after bone injury may have the same negative effect as continuing to smoke.

Fall (Fracture) Prevention

Physical therapists can have a major impact on fall prevention, contributing to the savings of high costs to the health care industry by assessing for risk factors and preventing falls that lead to fractures (see Boxes 27-19 and 27-20).

Given the risk for fracture and other complications and associated emotional and monetary costs, falls are of significant concern for older adults, their families, and the health care system. Complications caused by falls are the leading cause of death from injury in men and women older than 65 years⁴³⁹; a cluster of falls has been observed in older individuals during the months preceding death.¹⁶⁰

INCIDENCE

Half of all older adults who fall die as a direct or indirect result of that fall; men are more likely to die after a fall than women. The fall rates and mortality rates from falls are on the rise in the United States.^363,392 Other important statistics include the following:

• 13,700 people aged 65 years and older died from falls last year in the United States.⁷³

• At least one out of every four adults aged 65 and older will fall at least once during the next year; it is likely that older adults are falling even more often than is generally reported.⁵⁰

• Some sources say that one out of every three adults 65 years of age and older fall each year.^181,203

• 14% of adults who fall return to the hospital within 2 weeks.

• Falls are the second leading cause of traumatic brain injury among persons age 65 and older.^91,352

• Older adults who fall often sustain more severe head injuries than their younger counterparts.

• Falls are a major cause of intracranial lesions among older persons because of their greater susceptibility to subdural hematoma.⁹¹

• Even among older adults who do not sustain an injury during a fall, half cannot get up off the floor; this is a predictive factor for functional decline and/or death.^500,503

• The complaint of dizziness is one of the most common reasons older adults visit the doctor; the incidence of dizziness doubles, triples, and quadruples decade by decade from 60 to 80 years of age.⁵⁴¹

• Less than half (45%) of these cases (dizziness) are caused by vestibular problems.

RISK FACTORS AND RED FLAGS

Complex layers of skill are required to maintain balance in the upright position. Strength, coordination, endurance, flexibility, vision, vestibular control, and hearing are just a few of the skills involved.

At the same time, there are more than 400 risk factors identified for falls. It may be best to focus on the most common risk factors that are modifiable. Age is certainly a primary risk factor, and although age itself is not modifiable, we must be very aware of which adults are at risk requiring screening and intervention (Box 27-20). The rates of falls and fall injuries increase with age; adults 85 and older are four to five times more likely to injure themselves in a fall than adults ages 65 to 74; the risk of being seriously injured in a fall increases with age.⁴⁷⁷

Movement impairments, cognitive deficits, errors in judgment, and an unsafe environment are common hazards for the aging adult. Gait changes such as an increase in base of support or stride width increases the risk of falls.²⁶² The use of an assistive device such as a cane or walker is a risk factor, especially when learning to use it for the first time. Incontinence (including functional incontinence) is a risk factor by itself but when combined with any of these other risk factors raises the risk even more.

Gait or balance instability combined with muscle weakness is among the highest risk factors.¹⁶ Combine any one of these with side effects of medication, the use of alcohol or other drugs (especially when combined with medications), and multiple comorbidities and the risk for falls increases disproportionately.

Many gait disturbances really are a reflection of underlying red flag histories and risk factors. For example, visual impairments can cause increased sway and increased stride width. A past history of falls is a predictor of fear of falling, and a fear of falling will lead to changes in gait such as shorter stride length and slower speed.

Past history of joint replacement (knee) increases the risk of tripping, which increases the risk of falling and injury.³¹⁵ Painful feet from bunions, corns, overgrown or ingrown toenails, and other podiatric conditions are reported by 50% of older adults when asked. Loss of protective sensation in the feet occurs with diabetes or other peripheral neuropathies.

Neuromusculoskeletal impairments such as muscular weakness, loss of motion, and balance instability, especially when combined with comorbidities such as arthritis, Parkinson’s disease, multiple sclerosis, stroke, and so on, can result in positive Trendelenburg’s sign, uneven stride length, limping, uneven weight bearing, and many other changes in gait pattern.

Comorbidities such as osteoporosis, arthritis and other orthopedic problems, limb amputation, diabetes, dementia, chronic lung disease, stroke, and heart disease are actually more important than polypharmacy (use of four or more medications of any kind) as risk factors for falls, although polypharmacy is still an important risk factor.²⁷²

Many of the risk factors fall under the category of red flag histories, too. A past history of falls is one of the most important red flag histories. Obtaining an accurate history can be very challenging. Older adults may forget or deny problems with balance, coordination, and falls (or near falls). They may have lost self-confidence or experience postfall anxiety. Often they modify their behavior and activity level to avoid anything that might cause a fall, so they can honestly answer that they are not having any trouble with falls and have not fallen in the last weeks to months.

Meanwhile, their hygiene is poor because they are afraid to get in and out of the tub or shower. They may restrict and even eliminate community activities for fear of falling. Fear of falling (and especially the fear of not being able to get up) leads to self-imposed functional limitations such as prolonged sitting and all of the natural sequelae that come with an increasingly sedentary lifestyle. Predictors of fear of falling include the following:

• Past history of falls

• Use of assistive device

• Balance or gait instability

• Depression or anxiety

Gait and Movement Characteristics Associated with Falls

In the older adult, gait disturbances and gait changes are often an outward manifestation of an inward or other problem. The therapist should not seek to change the gait pattern until the underlying cause of the problem is known. Consider all of the following gait characteristics associated with falls and assess carefully. Here are just a few³¹:

• Decreased gait speed and stride length (linked with weak hip extensors and ankle plantar flexors, reduced push-off phase, reduced ability to propel the body forward during gait)

• Increased stride frequency (linked with muscle weakness and impaired balance requiring increased duration of double support)

• Increased (wider) stance (neurologic changes in diabetes or other conditions, muscle weakness)

• Unsteady gait (speed changes abruptly when unintended and/or person cannot adopt new movement patterns when the task requires it; alcohol or other drug use, dizziness, side effect of medication, decreased ankle/knee proprioception)

• Grabbing for support or stumbling

• Decreased medial-lateral sway (gluteus medius weakness)

• Unsafe or incomplete transfers

• Poor sitting balance; difficulty sitting or unsafe sitting down

• Difficulty rising from a seated position

Visual Impairment

Bifocal or multifocal eyeglasses combined with decreased contrast sensitivity and decreased depth perception lead to bending the head up and down to see the edge of a step. Decreased peripheral vision results in increased postural sway necessary to find center; with decreased reaction times, client cannot regain lost balance, resulting in an injurious fall.

Blindness and visual impairment are among the 10 most common causes of disability in the United States, associated with shorter life expectancy and lower quality of life.³⁵³ Visual impairment (especially combined with cognitive deficits) can lead to errors in judgment such as climbing up on counters, overreaching, and the use of step stools, resulting in falls.

The therapist can assist in identifying possible untreated visual impairment by asking a few simple visual screening questions and making an appropriate referral when indicated:

• How much difficulty would you have recognizing a friend across the street? [Choose one.]

No difficulty	Some difficulty
Moderate difficulty	Extreme difficulty

• How much difficulty do you have watching television? [Choose one.]

No difficulty	Some difficulty
Moderate difficulty	Extreme difficulty

• When was the last time you had an eye examination in which the pupils were dilated (you had to wear the wraparound sunglasses after the examination)?

SCREENING QUESTIONS TO IDENTIFY HISTORY OF FALLS

It may be best to avoid asking the question, Do you have a fear of falling? It is less threatening to ask about the degree of confidence in performing an activity, especially for people who view admitting fear as a sign of weakness.^302,502 It may be better to ask questions with answers on a continuum from “no confidence” to “complete (100%) confidence.” For example:

• How confident are you when walking on sidewalks, grass, or uneven surfaces? [Choose one.]

Not confident at all	Slightly confident
Moderately confident	Completely confident

• How confident are you when getting in and out of a car? [Choose one.]

Not confident at all	Slightly confident
Moderately confident	Completely confident

• How confident are you when using a public restroom? [Choose one.]

Not confident at all	Slightly confident
Moderately confident	Completely confident

Follow-up questions may include the following:

• In the past month, have you had any falls?

• In the last month, have you slipped or tripped or lost your balance and almost fallen?

• In the last month, have you hit against furniture and bruised yourself?

• In the past month, have you landed on the floor? If yes, were you able to get up by yourself or without help?

TESTING

Tests and measures are important in identifying individuals at risk for falls and finding ways to reduce risk factors and prevent falls. The therapist should collect baseline data using validated, reliable tests, keeping in mind that many tests do not identify why the individual is at risk or what intervention strategies would be most effective.

Advances in technology are beginning to provide computerized assessments of sensory integration and motor control that can objectively identify and differentiate balance system disorders (e.g., NeuroCom, Biodex). Since these are not yet available in all facilities, other test measures must be relied upon. For example, the Semmes-Weinstein monofilament test (see Fig. 11-15) can be used to check the protective level of sensation in the feet; impairment of this peripheral system could be the primary risk factor for falls and subsequent fracture.

Decreased sensation in the feet associated with diabetic neuropathy can affect both the timing and quality of gait, requiring retraining of the somatosensory and vestibular systems to help compensate for the somatosensory deficit.^398,399,541 A neurologic miscue can create footdrop and the toe hitting the ground can cause a fall, easily leading to a hip fracture or broken arm.

A loss of protective sensation and diminished information being received by the brain about how much muscle to use at corresponding sequences of toe-offs during gait can occur. Gait and strength training are important in the management of large fiber neuropathies when impaired vibration, depressed tendon reflexes, and shortening of the Achilles tendon occur.⁵²⁸

At the same time, keep in mind that diabetes gait may occur independent of sensory impairment. The increased joint movement, wider stance, and slower pace demonstrated in some individuals with type 2 diabetes may be neurologic in origin and not related to muscle weakness or loss of sensation in the feet.^398,399

Test for ankle and knee proprioception. Determine the lowest threshold for detecting joint movement, determine the accuracy of joint position sense by comparing or matching each joint to the contralateral joint, and perform the joint repositioning test (test limb segment repositioning without the aid of vision).

Dizziness can be due to benign paroxysmal positional vertigo (BPPV) caused by particles containing calcium collected in a semicircular canal provoking episodes of spinning vertigo when the head is moved into certain positions. A canalith repositioning procedure (e.g., Epley maneuver, canalith repositioning treatment or CRT, liberatory maneuver) “cures” this problem by repositioning the person (from sitting to side lying or supine) to move particles out of the canal into the utricle, where they can be reabsorbed.

Test for BPPV by performing the Dix-Hallpike maneuver: assist the patient from sitting to supine with the head extended over the edge of the treatment table and rotated 45 degrees to the side of the suspected ear. A positive test result is present when nystagmus is induced after a delay of about 10 seconds. See further discussion in Chapter 38.

TEST FUNCTIONAL LIMITATIONS

The therapist should use a standardized fall assessment tool and use it consistently. An excellent resource for test tools is available: Falls Prevention for Older People: Resources: Screening Tools (http://www.fallsprevention.org.au/resources.htm; accessed July 17, 2007).

Tests for functional limitations are useful but do not necessarily identify the cause(s) of balance dysfunction. Many tests are available; the therapist should choose one that best matches the individual’s current level of functioning. Some examples include the following:

• Berg Balance Scale: 14-item test measures balance on a continuum from sitting to standing. Valid and reliable measure of balance in older adults; predictive of individuals at risk; helps goal setting and directs intervention; use with lower-functioning patients.

• Timed Up and Go Test (TUGT): used to screen individuals at risk for falls. The client must be able to follow directions. Score of 13.5 seconds indicates that the individual is at risk for falls.

• One-Legged Stance Test: measures postural stability needed to make turns, climb stairs, get dressed, get in a car, step into a bathtub, or step up onto a curb. Risk of falls increases two times if test score is less than 5 seconds; client is at risk if response is 12 seconds or less; marginal risk if response is 13 to 20 seconds; 20+ is considered “safe”; the individual must not sway more than 45 degrees to remain in the “safe” category.

• Sit-to-Stand: must be able to rise from a chair 10 times without using the arms in less than 20 seconds.

• Four Square Step Test (FSST): reliable, valid, easy to administer and score; timed test to assess the rapid change in direction while stepping over low objects and movement in four directions; requires higher level of cognitive function and ability to shift weight from one foot to the other while changing direction. Consider using with adults who report falls or near loss of balance as a result of hurrying. Correlates with Functional Reach Test and Timed Up and Go Test]; this means the tests measure similar constructs, so only one of the tests needs to be administered.¹⁰⁵

Predictive fall risk information can also be obtained and can be useful when putting together the plan of care; fall risk assessment for use with the acute care inpatient population and assessing fear of falling may be appropriate (Box 27-21). No one scale best predicts falls risk in older adults. The Activities-Specific Balance Confidence (ABC) Scale and Falls Efficacy Scale (FES) are highly correlated with each other. These two tests are moderately correlated with Survey of Activities and Fear of Falling in the Elderly (SAFE).²⁰⁵

Box 27-21 PREDICTIVE FALL RISK ASSESSMENT

• Functional reach test: must be able to reach 6 or more inches

• Tinetti’s Performance-Oriented Mobility Assessment (POMA)/Tinetti’s Balance Index: objectify gait and balance; predict risk of falls; can be used with people who have an assistive device; does not detect small changes in gait deviation—Gait Abnormality Rating Scale (GARS) is better for assessing early, minute gait deviations

• Dynamic Gait Index: provides predictive fall-risk information

• Gait Abnormality Rating Scale—Modified (GARS-M): used to assess risk of falling in community-dwelling, frail older adults based on several gait variables

• Physiologic Profile Assessment (PPA): series of simple tests of vision, peripheral sensation, muscle force, reaction time, and postural sway that are easy to administer quickly with minimal equipment²⁹⁰

• Measurement of vital signs and assessment for postural hypotension: these are important assessment tools in predicting falls

For Use with Acute Care Inpatient Population—Fall Risk Assessment

• STRATIFY: St. Thomas’s Risk Assessment Tool in Falling Elderly Inpatients

• Hendrich II Fall Risk Model (http://www.hartfordign.org/publications/trythis/issue08.pdf)

Fear of Falling

• Falls Efficacy Scale (FES): good for adults who are frail

• Survey of Activities and Fear of Falling in the Elderly (SAFE): assesses 11 activities of daily living

• Activities-Specific Balance Confidence Scale (ABC): measure of balance confidence; good with higher functioning older adults; used in studies of amputee populations

The therapist should adopt a task-or functionoriented approach. This requires analysis of all the systems involved in the required movement. Rather than focus on individual exercise movements, identify the systems involved in the task and direct intervention to each of those systems.

For example, suppose the patient’s goal is to be able to pick up objects from the floor. Physical therapy goals are to improve reactive responses to external challenge during stance and ambulation activities as measured by the following: Goal 1—Increase Berg Balance Scale score from 34/56 to 50/56 in 6 weeks; Goal 2—Increase Tinetti’s Performance-Oriented Mobility Assessment (POMA) score from to 19/28 to 24/28.

The intervention should be customized for each individual, targeting the specific underlying impairments, which may include the following:

• Task-specific activities in sitting, standing, and walking (including reaching; weight shifting; progressing from flat surfaces to rocker board, curbs)

• Functional strengthening of the ankle, hip, and trunk muscles

• Range of motion in the trunk, hip, lower extremity (especially ankle)

• Static and dynamic balance activities with lateral sway, reach, grasp, manipulation of arms

• Treadmill training

Keep in mind that general strengthening is not enough. Specific muscle groups must be targeted and given enough resistance to build strength. The ankle is considered the most important joint governing balance.⁵³⁹ Older folks often have reduced ankle motion and strength; these deficits are linked with reduced balance.³²³ Check for loss of ankle motion; mobilize the calcaneus before stretching. Resistive exercises that produce overload of the hip extensors or ankle dorsiflexors are more effective in improving balance and reducing falls than general low-resistance exercises for the lower extremities.⁹⁵

EXERCISE AND FALL PREVENTION

Three types of exercise that can help prevent falls and fractures are balance training (prevents falls), strength training (builds bone and muscle), and aerobic training (builds muscle and endurance).

Walking while performing an additional attention-demanding cognitive task is a means to measure whether the client is able to walk automatically. The therapist can assess for dual-task interference, which is the worsening of performance of the main task (e.g., walking) as a result of simultaneously performing an attention-demanding cognitive task (e.g., counting backward).

Automaticity of the main task is reflected by a low or absent dual-task interference effect. Nonautomaticity can have an impact on daily living; gait changes caused by performing an additional cognitive task while walking are associated with increased risk of falling among older adults.^36,520

STEPS TO TAKE

Almost all hip fractures in older adults (over 65 years) are caused by falls, and very few are spontaneous, answering the question of whether falls are the result of fractures or vice versa.³⁷⁶ Hip fractures among older adults occur mainly in well-known environments, during everyday activities, and without overwhelming hazards, emphasizing again the importance of fall prevention/fracture reduction programs for all adults over age 65 years.

The CDC has recommended community-based falls prevention programs as an effective strategy based on research identifying interventions that can reduce falls. The therapist can be very instrumental in falls prevention by reviewing each of these with all clients age 65 and older. Four key fall prevention strategies are the following:

• Review of medications to reduce side effects and interactions

• Annual eye examination

• Regular exercise

• Reduction of fall hazards in every room of the home or facility

Modifying the environment is important; it may not prevent falls but it may reduce the severity of injury. The therapist should have the client and/or family complete an environmental safety check. Some studies show that this step is more effective when people are provided with a checklist and encouraged to make the changes themselves. An excellent checklist is available.³⁷¹

Fall-proofing homes; fall prevention education; osteoporosis and fall assessment; osteoporosis prevention (see Chapter 24); and exercise programs to improve balance, coordination, flexibility, strength, endurance, breathing, and posture are all important components of fall prevention and subsequent fracture prevention. Exercise to address all these components is key in fall prevention.⁴⁵⁸ For example, lower extremity weakness or loss of motion, particularly at the ankle and knee, is significantly associated with recurrent falls in the older adult population.^323,539

Specific intervention programs,⁵⁰⁴ exercise suggestions,^162,170,450 and educational materials^18,216 are available (Box 27-22). Sometimes even the simple step of teaching clients adequate hydration can improve their muscle strength, coordination, and balance, reducing risk for falls (see the section on Dehydration in Chapter 5).

Box 27-22 RESOURCES FOR FALLS ASSESSMENT AND PREVENTION

1. American Geriatrics Society, British Geriatrics Society, and American Academy of Orthopaedic Surgeons Panel on Falls Prevention: Guidance for prevention of falls in older persons, Ann Long Term Care 9:42-47, 2001. Available on-line at http://www.healthinaging.org/public_education/falls_index.php. Accessed June 1, 2008.

Falls: General information

Medical Evaluation of Falls

Choosing a Cane or Walker

Choosing and Starting an Exercise Program

Improve Your Balance in 10 Minutes/Day

Decrease Your Risk of Falling

Tips for Patients with Low Vision

2. Department of Health and Human Services (HHS), Bureau of Primary Health Care: Lower Extremity Amputation Prevention (LEAP) program. Available on-line at www.hrsa.gov/leap. Accessed June 1, 2008.

3. Falls Prevention Project for Older Adults offers program manuals and training resources. Available on-line at www.temple.edu/older_adult. Accessed June 1, 2008.

4. Fall Risk Assessment for Older Adults: The Hendrich II Model. Available on-line at http://www.hartfordign.org/publications/trythis/issue08.pdf. Accessed June 1, 2008.

5. Falls Prevention for Older People: Resources: Screening tools. Available on-line at http://www.fallsprevention.org.au/resources.htm. Accessed June 1, 2008. Excellent web page that describes various testing tools for falls.

6. National Center for Injury Prevention and Control (NCIPC): Preventing falls among older adults. Available on-line at http://www.cdc.gov/ncipc/duip/preventadultfalls.htm. Accessed June 1, 2008. Lots of great patient education materials, checklists, posters, prevention strategies.

7. National Safety Council: Falls in the home and community. Available on-line at http://www.nsc.org/issues/fallstop.htm. Accessed June 1, 2008.

8. Stevens JA: Falls among older adults—risk factors and prevention strategies. Falls free: promoting a national falls prevention action plan. Washington, DC, 2005, National Council on Aging. Brochures and posters available in English, Spanish, and Chinese are available at http://www.cdc.gov/ncipc/pub-res/toolkit/brochures.htm with additional information at http://www.cdc.gov/ncipc/pub-res/toolkit/toolkit.htm. Accessed June 1, 2008.

Computerized assessments of sensory integration and motor control can objectively identify and differentiate balance system disorders. Through advances in technology, therapists are now better able to identify the underlying impairments that may increase a person’s risk for falling.^368,525 In addition, clinical risk factors predictive of fracture (e.g., age, gender, height, weight, use of walking aid, current smoking) have been identified. The presence of five or more of these factors increases the rate of fracture (tested in white women).⁵³¹ These models have not been validated in other population groups.

Instituting and following a fall protocol in an extended or acute care facility may be able to reduce the incidence of repeated falls. The therapist can help staff set up a study to find out what time of day most falls occur and establish well-supervised small group activities during those times, especially for residents with dementia who are more likely to be put by themselves, get bored, and attempt to get up without assistance and fall. Residents of long-term care facilities may require individualized exercise interventions that can be adapted to their changing needs in reducing falls.³⁷⁵

Current use of physical restraints with acute care clients or residents of long-term care facilities is based largely on the assumption that these devices prevent falls and fall-related injuries. Numerous studies have reported a significant incidence of falls and injuries in restrained older adults rather than a lower risk of falls and injuries. With growing acceptance of restraint-free care as a standard of practice, therapists can be instrumental in educating personnel in these facilities of these findings when instituting a program.^68,505

A THERAPIST’S PERSPECTIVE

The vestibular system controls head, neck, and eye movements and is certainly an important component of balance and falls prevention. The three semicircular canals positioned in each spatial plane accurately sense head position and rapidly send signals to the eyes to keep our vision stable. After the age of 40, the number and size of vestibular neurons decrease. In individuals over the age of 70, 40% of the vestibular sensory cells are gone.^40,471

Vestibular impairment or dysfunction is certainly a possible cause of falls, and the therapist should test for this and intervene appropriately, but often the underlying etiologies are impairments of the peripheral systems feeding into the vestibular system. The vestibular system may react too little or inappropriately because external stimuli are deficient. Keep in mind that there may be other causes of vestibular system failure, which may not be failure at all but merely compensation for impairment or failure of other systems.

Take into consideration motor, visual, and especially oculomotor, vestibulomotor, and oculovestibular reflexes; it is not a single-system issue. The visual or ocular system determines movement and position in space and provides visual reference points. And the proprioceptive or somatosensory system consisting of pressure sensors in muscles, tendons, and joints (especially in the lower extremities) senses gravity and joint position. Any change in these systems can result in dizziness, fear of falling, and limited activity, leading to increased postural instability and contributing to further weakness and imbalance in a downward declining spiral of events.

Consider the effects of macular degeneration, loss of peripheral vision, and the loss of visual cueing mechanisms from these systems. A person may be able to compensate with one problem or system dysfunction, but when all three systems are impacted, it is much more difficult. The person starts to experience dizziness as the vestibular system tries to increase input. The person’s natural tendency is to sit more to avoid dizziness and falls.

Sometimes use of a simple cane to increase peripheral messages can make a big difference. But what is the typical response to this? “That will make me look old.” “I’d rather fall than use that thing.” Issues of pride enter in; the individual is unwilling to use a cane to help increase proprioceptive cues to make up for a loss of vestibular, visual, or motor input. You may need to have an honest, frank discussion with that person. Try to reframe the client’s view of the situation into something more acceptable; for example, help the individual see this as a short-term situation or even consider using a more direct approach. For instance, convey the following information to your patient/client:

Studies show that 50% of the people over 65 who fall fracture their hip and do not return home from the hospital. They often end up in a nursing home or extended care facility. Fifty percent of those people die within 1 year. Are you going to let a simple cane keep you from going home? If you do not want to use a cane, then how about getting a walking stick and letting me help you learn how to use it to your best advantage?

The therapist can also help older adults determine their own problem list and solutions in order to effect successful changes in behavior by asking the following questions²⁷¹:

• What do you think is the problem?

• What can be done to change your situation?

Alternatively: What do you think will help?

• What needs to happen for you to be able to _________________ (repeat what the person just told you)?

• Can you do it? Can you _________________ (repeat back what the person said needs to happen).

• Will you do it?

If the patient/client hesitates, you can ask, “What is one thing you CAN do to improve matters?

The therapist can also make some changes in how he or she practices in regards to screening individuals for falls risk, reducing or modifying risk factors, and preventing falls leading to fractures. If implementing a falls screening and prevention program for your facility seems too overwhelming, then at least choose one test and perform it consistently for 6 months or 1 year. Consider providing and/or participating in health fairs offering balance and posture screening.

Put together a task force with the express purpose of developing a screening checklist to fit your population base. Complete the checklist for every patient/client and conduct appropriate test measures. Make an appropriate referral sooner rather than later.

Stress Reaction/Fracture

In the case of individuals reporting isolated or pinpoint pain of the lower extremity associated with overuse in the presence of negative radiographic examination (x-ray), the therapist may need to assess further for the possibility of a stress fracture. This is also true for the client who shows minimal improvement (or a worsening of symptoms) following therapy intervention.

Applying a translational, rotational, or impact stress to the bone often reproduces the symptoms when the stressed bone lies deep within the tissue. Testing may start by applying a striking (percussive/compressive) force through the heel as the client lies supine and observing for any associated increase in painful symptoms, especially at the hip or groin. Pull the leg into a position of internal rotation and resist as the person tries to externally rotate the leg; then move the leg into external rotation as the person tries to internally rotate the leg. For a differentiation of stress reactions of the femoral neck versus the pubic ramus, see Box 27-23.

Box 27-23 DIFFERENTIATION OF STRESS REACTION/FRACTURE

Pubic Ramus

• Adductors may be in spasm (adductor avulsion from stress fracture at the inferior ramus); limited abduction

• Negative heel strike/percussion test result

• Pain with activity that is relieved with rest, usually no pain at night

• Pain with resistance to the muscles of adduction and external rotation; positive Patrick’s or FABER (hip and knee flexion, hip abduction, hip external rotation) test (e.g., pain is reproduced as the person tries to internally rotate from a position of external rotation)

• Gait may be normal or antalgic depending on the fracture location

Femoral Neck

• Vague, nonspecific description and onset of pain; unrelieved by rest; aggravated at night by rolling onto that side

• Positive Trendelenburg’s sign (see Fig. 23-14) with compensated gait pattern

• Positive heel strike/percussion test; symptoms reproduced with hopping

• Positive test of femoral neck integrity (pain as person tries to externally rotate from an internally rotated position; may be unable to even assume test position in passive internal or medial rotation)^*

• Noncapsular pattern (capsular pattern of the hip is defined as gross limitation of flexion, abduction, and medial rotation and slight limitation of extension with little or no limitation of lateral rotation)

• Localized tenderness at the greater trochanter unrelieved by treatment intervention for bursitis; pain may occur in the buttocks and/or groin

Tibia

• Painful pinpointed symptoms reproducible on palpation, frequently bilateral (one side more symptomatic than the other side); must be differentiated from shin splints

• Increased pain on weight bearing and walking (person assumes a wide-based waddling gait)

• May have a positive reaction to painful heel strike (more common in a hip fracture); symptoms reproduced with hopping

Adapted from Ozburn MS, Nichols JW: Pubic ramus and adductor insertion stress fractures in female basic trainees, Mil Med 146(5):332-334, 1981.

^*This may be differentiated from trochanteric bursitis, which is characterized by painful hip abduction and lateral rotation (but not medial rotation).

Any suspicion of stress reaction/fracture warrants communication with the physician. Further imaging studies may be necessary. Any woman with a stress fracture should be evaluated for the female athlete triad (amenorrhea, eating disorder, osteoporosis). Treatment of the underlying factors that contribute to the injury is important, including these three factors.⁵⁵⁰

Rehabilitation will vary depending on the age, condition, and goals of the affected individual. For example, rehabilitation for military personnel will differ greatly from that prescribed for a postmenopausal woman. Specifics of progressing an exercise program are available.⁴²⁷

Acute Care and Complications

Complications of fractures require vigilance on the therapist’s part and possibly quick action. Significant swelling can occur around the fracture site, and if the swelling is contained within a closed soft tissue compartment, compartmental syndrome may occur (see the section on Soft Tissue Injuries in this chapter). Because of the progressively increased intracompartmental pressure, nerve and circulatory compromise can occur. This condition may be acute or chronic. The compartment becomes exquisitely painful.

A thorough sensory and motor examination may be warranted. If the therapist notes skin changes, decreased motor function, burning, paresthesia, or diminished reflexes, physician contact is necessary. Permanent damage and loss of function may result if this condition is not treated. The therapist’s examination may be helpful in establishing the extent of the injury and baseline function.⁹⁹

Another complication associated with fractures is fat embolism, a potentially fatal event. The risk of developing this condition is related to fracture of long bones and the bony pelvis, which contain the most marrow. The fat globules from the bone marrow (or from the subcutaneous tissue at the fracture site) migrate to the lung parenchyma and can block pulmonary vessels, decreasing alveolar diffusion of oxygen.

The initial symptoms typically appear 1 to 3 days after injury, but this complication can occur up to a week later. Subtle changes in behavior and orientation occur if there are emboli in the cerebral circulation. There may also be complaints of dyspnea and chest pain, diaphoresis, pallor, or cyanosis. A rash on the anterior chest wall, neck, axillae, and shoulders may develop. The onset of any of these symptoms warrants immediate physician contact.

Individuals with acute VCFs (see Fig. 24-5) can be difficult to treat, because pain and fear can be severe. Even when extra care is taken with logrolling techniques, transitional movements can be exquisitely painful, with the client crying and begging the therapist to stop.

Arranging for premedication 45 to 60 minutes before treatment is advised, followed by modalities to modulate the pain and promote relaxation before attempting movement or exercise. Adaptive equipment, from wheelchair modifications to spinal orthotics to assistive devices (e.g., reachers/grabbers, stocking aids, raised toilet seats, bed grab bars), helps to improve posture, function, mobility, confidence, and independence.

The therapist must be alert to other complications that can occur following fracture, such as breakage of wires, displacement of screws, loss of fixation, refracture, delayed union and malunion, and infection.⁴⁵¹ Anyone on bed rest is at risk for complications from immobility, including constipation, deep vein thrombosis, pulmonary embolism, and pneumonia.

Fracture Rehabilitation

Like medical treatment, fracture rehabilitation is shaped by fracture type, need for reduction, presence of instability after reduction, and functional requirements of the affected individual. Postoperative rehabilitation begins anywhere from immediately to within 1 week after surgery depending on the physician’s protocol.

There are some widely accepted guidelines and rehabilitation protocols for various types of fractures (e.g., Neer rehabilitation program for shoulder fractures, Vanderbilt program, Tinetti protocol of balance exercises for rehabilitation from hip fractures).^280,501 The American Academy of Orthopaedic Surgeons offers guidelines for the rehabilitation of many different types of fractures. Several publications with fracture rehabilitation protocols are available specifically for the physical therapist.^{55,279,281,317,382}

Mortality rates following hip fractures in older adults may be improved by a more intensive rehabilitation program immediately after the operation. The best predictor of mortality immediately after hip fracture up to 1 year after fracture is the inability to stand up, an indicator of frailty.¹⁸⁷

Older adults admitted for care of a fall-related hip fracture should be evaluated early in their hospital stay to determine risk for falls following discharge. Indicators may include a previous history of falls and prefracture use of an assistive device for ambulation. The plan of care should include balance and mobility training to prevent future falls. A previous history of falls is a risk factor for future falls; poor balance, slow gait speed, and decline in ADLs have been identified in older adults who fall within 6 months following a hip fracture.⁴⁵⁷

Early mobilization accompanied by transfer training, and maintaining strength and range of motion after fracture surgery are essential to reduce the risk of deep vein thromboembolism, pulmonary or infectious complications, skin breakdown, and decline in mental status.

Following a fracture anywhere in the lower extremity (including the hip), some orthopedic surgeons advocate unrestricted weight bearing, advising the client to decide himself or herself how much weight to put on the leg. Stable fractures can usually tolerate weight bearing. Rotationally stable but potentially long unstable femur fracture may be allowed toe-touch weight bearing. Clients with vertically and rotationally unstable femoral fractures may be restricted to non–weight-bearing status using a wheelchair or electric scooter (if not in a spica hip cast).⁴¹⁴

Although immediate weight bearing may cause initial bone loss, the long-term success of achieving bone growth remains unchanged,⁴⁵⁴ and the short-term benefits of functional recovery and quicker return to independent living that accompany unrestricted weight bearing are important.^257,391

Again, depending on the type of fracture, some movements may be restricted to allow for proper fracture consolidation. Most importantly, a non–weight-bearing status can actually place greater forces on the hip as a result of the biomechanics involved in maintaining correct positioning of the lower extremity.^208,357 In the case of femoral neck or intertrochanteric fractures, there is little biomechanical justification for restricted weight bearing; indeed, there is far greater pressure generated from performing a hip bridge while using a bedpan (almost equivalent to the effect of unsupported ambulation).²⁵⁷

Partial weight bearing is usually considered 30% to 50% of body weight. Touch or touch-down weight bearing is 10% of body weight, but this is a subjective decision that is not easily determined. Allowing for unrestricted weight bearing according to the client’s tolerance (WBAT) is less restrictive, but the therapist must assess for intact cognition and decision-making abilities, intact sensation, upper body strength, vestibular function and balance, and proprioception before allowing unsupervised WBAT.

Early repair and physical therapy have been shown to reduce hospital stays, increase chances of returning home (rather than being discharged to a nursing facility or rehabilitation facility), reduce complications, and improve functional mobility and independence at discharge,^163,250 and are associated with higher rates of 6-month survival.^88,198 Therapists are encouraged to share the results of studies such as these with hospital administrators when developing fall and fracture prevention programs.

The literature supports recommending follow-up for strength and functional assessment 7 to 9 months after fracture.^438,454 Muscle strength around the hip remains weak after hip fracture, with joint arthroplasty requiring an exercise program for strengthening for 1 year or longer.^218,456 Short-term intervention with a therapist can be very cost effective in reducing refracture rates.^454,455

Older adults who receive physical therapy while still in the hospital following hip replacement for hip fracture are more likely to be discharged directly home rather than to a rehabilitation or assisted living facility.¹⁷⁵ People with hip fractures who receive additional home health visits are less likely to be hospitalized and more likely to need fewer medical visits, which usually translates into lower Medicare costs.²²¹

For clients with VCFs, the plan of care should include trunk extension strengthening and a cognitive-behavioral component to improve coping, especially for older adults. Improvements have been retained for at least 6 months in one randomized, controlled trial.¹⁵⁰

Osteochondroses

A number of clinical disorders of ossification centers (epiphyses) in growing children share the common denominator of avascular necrosis and its sequelae. These disorders are grouped together and referred to as the osteochondroses⁴³⁰ with multiple synonyms (epiphysitis, osteochondritis, aseptic necrosis, ischemic epiphyseal necrosis). There are additional eponyms based on the name of the person or persons who described the disorder as well, such as Kohler’s disease (tarsal-navicular bone disease), Osgood-Schlatter disease, and Legg-Calvé-Perthes disease.

The underlying etiologic factors and pathogenesis are similar in all these entities, and the clinical manifestations are determined by the stresses and strains present. Most susceptible areas are the epiphyses, which are entirely covered by articular cartilage and therefore poorly vascularized.

Osteochondritis Dissecans

Osteochondritis dissecans (OCD) is a disorder of one or more ossification sites with localized subchondral necrosis followed by recalcification. This condition affects the subchondral bone and the layer of articular cartilage just above. A piece of articular cartilage and fragment of bone separate and pull away from the underlying bone. These fragments can become loose bodies in the joint; the most common site of involvement is the medial femoral condyle.

OCD is caused by repetitive microtrauma resulting in ischemia and disruption of the subchondral growth. The articular cartilage softens, and fragment separation leads to cartilage injury that can progress to form a crater. Activity-related pain, swelling, and giving way are common symptoms. Pain is increased with passive knee extension and tibial internal rotation and relieved with tibial external rotation (Wilson’s sign).

X-rays and MRI help confirm the diagnosis. Management varies with the person’s age and the severity of the lesion and includes nonoperative management (activity modification, protected weight bearing, immobilization for 4 to 6 weeks) and operative treatment. Quadriceps strengthening and gradual return to activities follow immobilization. If conservative care is unsuccessful in bringing about healing, then surgery may be needed (e.g., microfracture, implant tissue to stimulate cartilage and bone growth).

Osteonecrosis

Overview and Incidence

The term osteonecrosis refers to the death of bone and bone marrow cellular components as a result of loss of blood supply in the absence of infection. Avascular necrosis and aseptic necrosis are synonyms for this condition.

The femoral head is the most common site of this disorder (sometimes called Chandler’s disease), but other sites can include the scaphoid, talus, proximal humerus, tibial plateau, and small bones of the wrist and foot. Avascular necrosis is the underlying cause for 10% of total hip replacement surgeries³⁶² and overall affects approximately 20,000 people annually, often between the second and fifth decades of life.²⁷⁰

Etiologic and Risk Factors

Osteocytic necrosis results from tissue ischemia brought on by the impairment of blood-conducting vessels. A minimum of 2 hours of complete ischemia and anoxia is necessary for permanent loss of bone tissue.²²⁴ The bony ischemia may be secondary to trauma disrupting the arterial supply or to thrombosis disrupting the microcirculation.

Bones or portions of bones that have limited collateral circulation and few vascular foramina are susceptible to avascular necrosis. Box 27-24 lists conditions associated with osteonecrosis. A number of these conditions are linked to osteonecrosis by the development of fat emboli (caused by altered fat metabolism) in the vascular tree of the involved bone.

Box 27-24 CONDITIONS ASSOCIATED WITH OSTEONECROSIS

• Idiopathic

• Trauma (e.g., fall)

• Systemic lupus erythematosus

• Pancreatitis

• Diabetes mellitus

• Hyperlipidemia

• Cushing’s disease

• Gout

• Sickle cell disease

• Alcoholism

• Obesity

• Pregnancy

• Medications

• Oral contraceptives

• Corticosteroids

• Bisphosphonates (under investigation)

• Organ transplantation (medication related)

• Human immunodeficiency virus (HIV) infection

• Radiation therapy (less common)

• Dysbaric disease (deep sea diving; rare)

The conditions associated with the development of fat emboli include alcoholism, obesity, pregnancy, pancreatitis, medications (e.g., oral contraceptives, corticosteroids), and unrelated fractures. Many cases of femoral head osteonecrosis are idiopathic (i.e., no known cause or risk factor can be identified).

Osteonecrosis has also been recognized as a complication in HIV-positive individuals; in fact, individuals who are HIV positive have a 100-fold greater risk of developing osteonecrosis than the general population.³⁵⁶ The exact mechanism for this remains unknown. It may be due to hyperlipidemia secondary to the use of protease inhibitors; however, avascular necrosis was reported before the era of highly active antiretroviral therapy (HAART).⁴¹⁶ It does not appear to be related to the degree of immunodeficiency.

More recently, the use of bisphosphonates has been linked with osteonecrosis of the jaw (sometimes referred to as “dead jaw syndrome”), especially after trauma to the teeth or bones of the jaw such as occurs with dental surgery (e.g., tooth extraction). The reason this happens is not entirely clear. Scientists hypothesize that since the jaw has a high rate of bone renewal in response to stress via generation of an inflammatory response by the gums and teeth, bisphosphonates keep osteoclasts from reabsorbing damaged bone cells in the jaw. The damaged bone builds up and eventually results in osteonecrosis.

This phenomenon is most likely to occur in individuals treated for bone cancer with intravenous bisphosphonates. The dosage of intravenous bisphosphonates can be as much as 12 times more than the oral bisphosphonate dosage prescribed for osteoporosis. Individuals with cancer treated this way also undergo other bone-weakening treatments (e.g., chemotherapy, radiation therapy).

Pathogenesis

Certain bones are more vulnerable to osteonecrosis than others. These bones are covered extensively by cartilage, have few vascular foramina, and have limited collateral circulation. The femoral head is a prime example of a bone at risk. The superolateral two thirds of the femoral head receives its blood supply almost entirely from the lateral epiphyseal branches of the medial femoral circumflex artery (Fig. 27-26).

Figure 27-26 Blood supply to the femoral head in a child. (From Bullough PG: Orthopaedic pathology, ed 3, London, 1997, Mosby-Wolfe, p 263.)

The only other source of blood for the femoral head is the medial epiphyseal artery (contained within the ligamentum teres), which has limited anastomoses with the lateral epiphyseal vessels. Hip dislocation or fracture of the neck of the femur can compromise the precarious vascular supply to the head of the femur. The talus, scaphoid, and proximal humerus are also susceptible to osteonecrosis.

As the ischemia progresses, repair processes occur but are not capable of preventing necrosis and deformation of the bone, such as flattening and collapse of the femoral head. The articular cartilage and acetabulum are usually spared until late in the disease process, but the articular cartilage may be lifted off the underlying bone, resulting in irreparable damage to the joint.²⁰¹ The entire process extends over many years, and unlike in osteochondrosis of immature bone (e.g., Legg-Calvé-Perthes disease), spontaneous healing never occurs.

Clinical Manifestations

Often no symptoms are observed during the initial development of osteonecrosis even though an ischemic condition of the bone exists.²⁰¹ Hip pain is the usual initial presenting complaint, with a gradual onset, sometimes of many weeks’ duration, before diagnosis. The pain may be mild and intermittent initially but will progress to become severe, especially during weight-bearing activities.

If the femur is involved, the pain may be noted in the groin, thigh, or medial knee area. An antalgic gait is noted, and pain provocation occurs with weight-bearing activities and hip range-of-motion exercises, especially internal rotation and flexion and adduction. The affected individual will report a slowly progressive stiffening of the joint. When fracture occurs, it is usually at the junction between necrotic bone and reparative bone, possibly extending down through the reparative interface to the healthy inferior cortex of the femoral neck.³⁴⁰

Eventually degenerative joint changes and osteoarthrosis occur at the involved hip joint; the pathologic process is often relentless, with collapse of the femoral head imminent in spite of medical intervention.²⁰¹

Osteonecrosis of the jaw is characterized by exposed bone in the mouth, numbness or heaviness in the jaw, pain, swelling, infection, and loose teeth. Delayed or poor wound healing after dental surgery may be the first indication of a problem. Crepitus as the jaw opens and closes may be present and is often described as like the sound of someone walking on ice.

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PROGNOSIS.

Osteochondroses

Osteochondritis Dissecans

Osteonecrosis

Etiologic and Risk Factors

Pathogenesis

Clinical Manifestations

MEDICAL MANAGEMENT

TREATMENT.

PROGNOSIS.

Legg-Calvé-Perthes Disease

Etiologic Factors

Pathogenesis

Clinical Manifestations

MEDICAL MANAGEMENT

TREATMENT.

PROGNOSIS.

Osgood-Schlatter Disease

Etiologic Factors and Pathogenesis

Clinical Manifestations

MEDICAL MANAGEMENT

TREATMENT AND PROGNOSIS.

References