New balance test could help predict falls in older adults

The scenario is common. An elderly person seems to be in good health until one day they suffer a fall and from then on their quality of life begins to deteriorate. Even if there are no serious consequences such as injuries, fractures or head trauma, falls usually lead to reduced mobility and consequently to a loss of independence and autonomy.

The problem is so worrisome – falls are the second leading cause of injury-related death among adults aged 65 and over in the world, according to the United Nations' World Health Organization (WHO) – that it is recommended that older people receive annual balance and mobility tests as part of their routine visits, regardless of the health care provider.

A study supported by FAPESP and carried out on 153 people between the ages of 60 and 89 was able to point out in one fell swoop changes to make this type of test simpler and more effective, and also demonstrated its predictive capacity, i.e. indicating the future risk of falling even among those who had good balance and mobility. The research results have been published in the journal BMC Geriatrics.

The current model of the balance test is simple and only requires the elderly person to remain in each of the four positions – parallel feet [bipedal], with one foot slightly in front of the other [semi-tandem], with one foot in front of the other [tandem], and balanced on one foot [unipedal] – for 10 seconds in order to check for balance and mobility problems. However, our study showed something we already suspected: 10 seconds in each position is not enough."

Daniela Cristina Carvalho de Abreu, coordinator of the Laboratory of Balance Assessment and Rehabilitation (LARE), Ribeirão Preto Medical School, University of São Paulo (FMRP-USP), Brazil

The study of 153 volunteers showed that the assessment can be much more effective if the test is summarized as observing whether the individual can remain in just two of the most challenging positions (preferably tandem and unipedal) for 30 seconds each.

"In the study, we also found that for every extra second [of the 30 seconds] that the elderly person was able to stay in the tandem or unipedal position, the chance of falling over the next six months decreased by 5%. This makes it possible to predict the risk of falling over a six-month period, which is important because the test can be done in the clinic, quickly and without the need for equipment," she added.

Abreu points out that in both the current model and the one proposed by the USP research group, the test is still considered primarily as a screening test. This is because, based on the results of the four-position balance test, more detailed and multifactorial assessments are recommended to understand whether the imbalance is related to muscle weakness, changes in postural alignment, sensory impairments, joint problems, or other factors. "What happens is that by performing the test for 30 seconds, we can not only identify individuals with subtle balance problems but also predict the risk of the elderly person falling in the next six months – making further investigation into the cause of this imbalance even more important," she says.

To come up with the new testing approach, the research group evaluated the 153 volunteers using conventional tests and extended time, following the participants for six months.

When the researchers divided the sample into those who had fallen and those who had not, the group who had fallen in the six months following the test was able to stay in the unipedal position for an average time of 10.4 seconds and in the tandem position for 17.5 seconds. Those who hadn't fallen remained in the unipedal position for 17.2 seconds and in the tandem position for 24.8 seconds.

"Our results, therefore, show that the 10-second hold test can only detect those with very severe balance problems and thus misses a significant proportion of people at high risk of falling. We therefore suggest that the time limit for the four-stage balance test should be set at more than 23 seconds," said Abreu.

The study also used a force platform – a device used to measure a person's sway on a platform while holding positions. The goal was to see if it was possible to predict the risk of falling based solely on how long a person could hold position or if the amount of body sway was an important parameter to consider.

Regarding the time limit, the results showed that all participants were able to maintain the bipedal position for 30 seconds, and most of the older adults were also able to maintain the semi-tandem position for 30 seconds. "In predicting falls in six months, only sway – medial-lateral amplitude of the center of pressure displacement [measured on the force platform] – in the unipedal position and time maintained in the tandem and unipedal positions were associated with the occurrence of falls in the elderly sample and, therefore, without any neurological conditions," she added.

Thus, although body sway measured on the force platform was shown to be a predictor of the elderly person's risk of falling after six months, the problem can also be verified by the length of time spent in the most challenging positions (tandem and unipedal). "This is important because it simplifies the test and guarantees access to it in any doctor's office or health center since the platform is an expensive piece of equipment," he says.

The researchers now hope that the results of the study will serve as a basis for implementing fall risk assessment for people aged 60 and over, from primary care to specialist consultations. "Our study has come a long way and has important implications for clinical practice. Although falls are the second leading cause of unintentional injury death in older people worldwide, and annual balance testing is recommended, it's rarely done in clinical practice. That's why it was important for us to find a model that didn't require any equipment, was simple [with only two positions], quick [60 seconds in total], and could predict falls," she adds.