Case 25- Falls and Anatomy Flashcards
Fall definition
A fall is an event which results in a person coming to rest inadvertently on the ground or floor or other lower level
The 3 types of balance
Static/ dynamic steady state- ie maintaining a steady position in sitting, standing)
Proactive- anticipation of predicted disturbance
Reactive- compensation with a disturbance
Walking needs all 3
Systems we need to stand and walk?
1) Afferent systems (sensory and pathways to CNS)- vision, hearing, vestibular system, proprioceptors, stretch receptors, afferents nerves
2) Spinal reflexes – spinal function and integrity of nerve pathways
3) Autonomic nervous system- vasovagal, autonomic stability
4) Cognitive Processing dementia, delirium , depression, Basal Ganglia, thalamus, cerebellar, cortical function (strokes, parkinsons, huntingtons, etc)
5) Optimal perfusion to the brain-cardiac output, arrhythmias, hypotension, autonomic instability
6) Efferent systems (motor pathways and effect on locomotor system) efferent pathways, joints, muscles, biomechanics, gait, sarcopenia
7) Other factors- bone strength, confidence (fear of falling). coping strategies, co-morbidity
Sarcopenia
Humans loose approx. 20-30% of their skeletal muscle mass between young adulthood and 80y . The loss isn’t equal- type 2 muscle fibres are predominantly lost which results in a greater decline in power compared to strength- muscle power is needed for quick postural reactions.
Things to do to reduce risk of falls
Visual correction is the most effective thing to do- fix cataracts, get new glasses etc
The second most effective thing is treating general balance and strength issues
Gait and falls
1) Visual difficulties- small hesitant uncertain steps
2) Vestibular- tend to veer to one side- often staggering to correct for this
3) Sensory- polyneuropathy means people cannot feel their feet – as a response to this and to maximise sensory input they tend to stamp their feet
4) Anxiety- hesitant, leaning slightly forwards looking at feet. Is a response to fear of falling but actually increases risk of fall as centre of gravity tilted forwards and less sensory input from eyes about surroundings.
5) Higher motor function- hemi-plegic gait from a stroke – unilat weakness
How does the Mid brain affect gait
Parkinsonian shuffling gait
Choreiform- uncontrolled writhing movement
Pathology which can cause gait changes
Cerebellar- ataxic “drunk” like wide based gait
Spinal lesions- diplegic gait- bilateral spasticity and weakness in muscles- scissoring gait
Myopathic gait- trendelenberg gait- waddling
Neuropathic gait- high stepping/ equine as cant dorsiflex foot so it would catch otherwise.
Pain- Antalgic gait
Conditions that may present as ‘falls’
Benign Paroxysmal positional vertigo Parkinson’s Disease Orthostatic hypotension Visual Impairment OA hips / knees/ ankles New diagnosis dementia Depression and anxiety Drug adverse effects Spinal stenosis Sarcopenia Peripheral neuropathy
Consequence of falls
1) Fear of falling
2) Impact on confidence/activity level/independence
3) Fractures and trauma- osteoporosis assement
History of falls
1) When does it happen? (posture/ position change/ situational/ precipitants?)
2) What happens? Detailed description of events, associated features, LOC, prodrome?, what happens afterwards?
3) Why do they think it happens?
4) What do they do when it happens or to stop it happening?
5) How is it affecting AODL?
A multifactorial assessment of a fall may include
1) Chronic conditions that affect mobility or balance (including arthritis, diabetes mellitus, stroke, Parkinson’s disease, and dementia).
2) Gait, balance, and mobility problems.
3) Osteoporosis risk.
4) Perceived impaired functional ability and fear relating to falling.
5) Visual impairment.
6) Cognitive, neurological, and cardiovascular problems.
7) Urinary incontinence.
8) Home hazards.
9) Polypharmacy (the use of multiple drugs) and the use of drugs that can increase the risk of falls, for example drugs that can cause postural hypotension (such as antihypertensive drugs) and psychoactive drugs (such as benzodiazepines and antidepressants).
Different meanings of dizziness
Light headedness (presyncope)- normally cardiovascular
Dysequilibrium/ Unsteadiness- experiment-normally due to poor vision or balance or peripheral neuropathy
Vertigo – the illusion of movement- normally to do with the vestibular system usually presents with nystagmus
Causes of abnormal gait
Antalgic gait (pain) Parkinsonian gait (extra pyramidal) Ataxic gait (cerebellar) High Stepping gait (neuropathic/ equine ) Cautious/ hesitant gait (anxiety/ fear of falling) Hemiplegic gait (unilateral weakness) Diplegic gait (bilateral weakness with spasticity) Waddling gait (Trendelenberg gait) – myopathic Stamping gait (peripheral sensory neuropathy)
What to test for in an examination of falls
Higher functions- Mood, Memory
Neurology- Vision, vestibular testing, cranial and peripheral, sensory, Rhomberg, Cerebellar signs (DANISH)
Cardiovascular- Heart sounds, Heart rhythm (ECG), Postural hypotension
MSK- Gait, joints, muscle strength, sit to stand, balance assessment, feet and footwear
Treatment/Interventions for falls
Adapt the treatment to the underlying cause
Safety
Reasonable adaptions
Goals of care
Falls- strength and balance training
Evidence based- improves physical, mental and functional performance.
3 of the most common modifiable risk factors for falls are- Muscle weakness, Balance deficits, Gait instability
Anatomy of the hip joint
- Femero-acetabular joint
- Ball and socket synovial
- Head of femur articulates with acetabulum (vinegar cup)
- Articular surfaces lined with hyaline cartilage, the non-articular surfaces are covered with synovial membrane. The Hyaline cartilage lines the acetabulum at the lunate surface in the fossa, The hyaline cartilage lines the head of the femur except the fovea
- Ilium, ischium and pubis form hip bone (innominate bone) and meet at acetabulum
Triradiate cartilage
Separates the Ilium, Ischium and the Pubis
Proximal femur- anterior view
Greater trochanter- on the lateral side, the lesser trochanter is on the medial side and inferior, they are connected by the Intertrochanteric line which forms the margin between the neck and shaft of the femur.
