Fall prevention and recovery are important topics to address in all aspect of patient care, but especially in the home healthcare practice setting. Interventions to prevent falls among the community dwelling older adult population are imperative, as one in four individuals over the age of 65 falls each year with 20% of those falls resulting in serious injury (Centers for Disease Control and Prevention, 2017). It is further concerning that there has been a 30% increase in the rate of fall-related deaths since 2007 (Centers for Disease Control and Prevention). Given that 55% of all falls occur in the home (Fall Prevention Center of Excellence, 2019), home healthcare therapists are at the front line of providing assessments and interventions before and after a fall occurs. A therapist's knowledge and intention to include evidence-based fall risk measures in care plans is vital to thwart the high incidence of falls and the associated negative sequelae.
Prevention strategies aimed at reducing fall risk include a comprehensive assessment of fall risk and should incorporate health screening and pharmacologic review. Interventions aimed at improving strength and balance impairments and home environment modifications should follow (Phelan et al., 2015). As it is not feasible to prevent every fall, having a preemptive plan to safely recover from the floor should a fall occur is critical. Remaining on the floor for an extended period of time after a fall can lead to serious medical issues such as pressure ulcers, dehydration, pneumonia, and even death (Barbosa et al., 2012). A prior study found that 20% of falls in older adults over age 65 resulted in the victim lying on the floor for 1 hour with 50% of those individuals dying within 6 months (Wild et al., 1981). Therefore, the negative outcomes related to falls and the associated recovery time warrant the inclusion of skilled educational strategies with intentional cognitive and psychomotor learning goals in therapy care plans.
Although there is no one universally accepted protocol or methodology related to fall recovery instruction, several resources are available to therapists for general guidance. Evidence is available for the timed supine-to-stand assessment and predominant motor patterns to complete floor rise (Klima et al., 2016), and interventions to improve floor rise ability using a six-session intervention focused on components of the task and body position among older adults (Hofmeyer et al., 2002). Clinical judgment regarding modifications to published fall recovery guides with consideration for each individual's physical presentation and medical diagnosis is warranted. Table 1 overviews and provides links to resources for guidance on developing step-by-step plans to recover from a fall. Although this table is not all encompassing, it does serve to provide useful templates for fall recovery education.
The Philips Lifeline(R) delineates three phases of fall recovery: the prepare phase, the rise phase, and the sit phase (Philips Lifeline, 2010). The prepare phase provides considerations leading up to recovery movement. This includes education emphasizing the importance of calling for emergency assistance through a life alert or local first responder, especially if an injury is suspected. The prepare phase incorporates a transition from the landing position to side lying in the direction of stable furniture using a rolling maneuver. The rise phase encompasses movement from the side lying position, to a four-point position, and then to a half kneel position with upper extremity support on the chair. It is notable that some individuals may find this position uncomfortable and even painful in the presence of prefall lower extremity pain or impairment; therefore, consideration for initiating emergency assistance should be discussed. Pauses with each transition to allow time for assessment of previously unrecognized injury and to reduce the risk of further injury is recommended. Finally, the sit phase consists of the movement from a half kneel position to a seated position with the upper extremity in contact with a chair as much as possible to stabilize and distribute weight bearing. Maintaining a seated position for at least 5 minutes before resuming activity in order to return to the baseline physiologic state is suggested (Philips Lifeline).
Implementing fall recovery training in the home healthcare setting is a crucial element to combat the negative impacts of lying on the floor after a fall occurs. Establishing a preventative action plan for steps to get up from the floor can help prevent further injuries related to prolonged time lying on the floor. Additionally, psychomotor practice may be incorporated into therapeutic exercise plans with the aim of minimizing biomechanically strenuous methods of transferring from the floor to a seated or standing position.
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