For older adults, applications for physical therapy go far beyond knee replacements and weak rotator cuffs to include everything from breathing problems to neurological injury, such as stroke or dementia, and with all a desire for fall prevention. In her role as Physical Therapist – Case Manager with Lifespark Home Health, Julie Varno evaluates newly referred clients and develops a treatment plan that addresses barriers to living a more active and engaged life. She also works directly with clients to help them get back to doing what they enjoy most.
“If a client is having falls, I always recommend a thorough evaluation by a physician to rule out other possible factors, like electrolyte imbalance, low blood pressure, or the side effects of medication,” Julie said. “Unfortunately, many of the drugs commonly prescribed for diabetes, high cholesterol, hypertension, overactive bladder, and anxiety can cause dizziness and sometimes muscle weakness.”It’s not always the smoking gun, she said, but it’s definitely worth exploring. “Once a client is cleared medically, the physician can prescribe PT or OT,” Julie said.
According to the Centers for Disease and Prevention, older people who’ve been hospitalized are at a much higher risk of falls during the four weeks after discharge than those who haven’t had a hospital stay. “Home health physical therapy and occupational therapy can help minimize that risk,” she said. Julie and her colleagues look at norm-referenced testing and data to gage, for example, how far a healthy, community-living 80-year-old person should be able to walk. Based on the client’s medical conditions and comorbidities, they will make reasonable adjustments to that goal and reassess after 30 and 60 days.
“Sometimes it’s my job is to let people know they’re reached a point where they’re no longer able to walk or get around easily without a walker or wheelchair,’ she said. “It doesn’t mean they can’t be active, but that they need to be active in a different way in order to mitigate the risk of injury from falls.”
Fear of falling
Although it might seem counterintuitive, clinical studies have shown, and Julie’s experience confirms, that older adults who are afraid of falling have a higher risk of falls than those who have a history of falls. The fear triggers an insidious spiral, Julie explained, that starts with the individual becoming less active, which leads to muscle weakness and joint stiffness. That, in turn, affects balance and the ability to react quickly. “A poorly placed rug or an attempt to reach outside their base of support can end up in a fall,” she said.
There is some justification for that fear. According to the National Safety Council, 38,742 adults aged 65 and older died from preventable falls in 2021, and nearly 2.9 million were treated in emergency departments.
To identify a fear of falling, Julie uses the Activities-specific Balance Confidence (ABC) Scale. The questionnaire asks clients to rate their confidence on a scale of 1 to 100 while imagining themselves doing certain activities, such as sweeping the floor, walking on an icy sidewalk, riding an escalator, getting in and out of the car, and walking in a crowded mall. “The test gives us a starting point: if they rate themselves lower than 67%, they’re at an increased risk,” she said. “After 30 or 60 days of intervention, we reassess to measure progress.”
What those interventions look like varies depending on the client’s degree of muscular weakness, joint stiffness, or pain. “If the client has arthritis and pain in their knees or a weak tibialis anterior muscle, they’re not going to feel very confident walking upstairs,” Julie said. “In addition to exercises, we might also try Kinesio tape, manual therapy, and/or bracing.” If the pain persists, she’ll reach out to the client’s primary care physician for further evaluation and to determine whether medication or a steroid injection might be helpful. If pain isn’t a barrier, Julie focuses on the building blocks: the cone of stability, joint flexibility and muscle strength, and the vestibular system.
Cone of stability
The cone of stability refers a person’s ability to move forward, backward, or sideways and then back to middle without losing their balance. With inactivity, that ability shrinks, leading to abnormal balance reactions. “It’s a classic case of ‘use it or lose it,’” she said. “Fortunately, agility and flexibility work, strengthening exercises, and balance drills can help people expand their cone of stability and regain their sense of balance so they can feel safe while being active.”
Joint flexibility and muscle strength
Range of motion in the toes, feet, and ankles is critical to balance, and although it tends to decrease with age, exercises can help restore ankle flexibility. Also essential to good balance is the tibialis anterior muscle which pulls the toes up and controls their descent. “The good news is that, like all muscles, it can be strengthened—and fairly quickly—by completing progressive resisted exercises,” Julie said.
The vestibular system enables people to judge where they are in space. With age, the system can deteriorate, leading to balance disorders. To restore the vestibular system, Julie helps clients relearn where middle is, how far they can go away from that center point, and how to come back to middle safely.
Dementia and motor action training
With a background in dementia care, Julie enjoys working with clients in memory care. “The beauty of balance is that it isn’t a cognitive task; it’s a reactionary system which means that even in individuals with early-stage dementia or memory problems, the body can be trained to react and balance,” she said. One approach is to help people with milder dementia learn to use a walker before they actually need one. “We use a ‘space retrieval’ test to give us a sense of the client’s ability to hold on to a small piece of information with increasing intervals of time,” Julie said. “If they can, we attempt to attach a motor action to a simple verbal cue so that down the road, when their memory and learning abilities have declined, using a walker will already be part of their normal routine.” When clients with dementia stay more mobile, it gives them greater independence and significantly decreases the burden of care on staff and family caregivers.
Julie’s relationships with Lifespark’s medical experts and outside physicians and Subspecialists are vital to her and her clients. “I rely heavily on them to give me as much information as possible about each client, and the physicians are appreciative of being kept in the loop,” she said. “We’re the boots on the ground, so if there’s a change in a client’s health, we’ll usually see it first and refer back to their doctor for further evaluation.”