To study risk factors for falling, we conducted a one-year prospective investigation, using a sample of 336 persons at least 75 years of age who were living in the community. All subjects underwent detailed clinical evaluation, including standardized measures of mental status, strength, reflexes, balance, and gait; in addition, we inspected their homes for environmental hazards. Falls and their circumstances were identified during bimonthly telephone calls. During one year of follow-up, 108 subjects (32 percent) fell at least once; 24 percent of those who fell had serious injuries and 6 percent had fractures. Predisposing factors for falls were identified in linear-logistic models. The adjusted odds ratio for sedative use was 28.3; for cognitive impairment, 5.0; for disability of the lower extremities, 3.8; for palmomental reflex, 3.0; for abnormalities of balance and gait, 1.9; and for foot problems, 1.8; the lower bounds of the 95 percent confidence intervals were 1 or more for all variables. The risk of falling increased linearly with the number of risk factors, from 8 percent with none to 78 percent with four or more risk factors (P less than 0.0001). About 10 percent of the falls occurred during acute illness, 5 percent during hazardous activity, and 44 percent in the presence of environmental hazards. We conclude that falls among older persons living in the community are common and that a simple clinical assessment can identify the elderly persons who are at the greatest risk of falling.

https://www.nejm.org/doi/pdf/10.1056/NEJM198812293192604

Risk factors for falls among elderly persons living in the community.

As people get older, they may fall more often for a variety of reasons including problems with balance, poor vision, and dementia. Up to 30% may fall in a year. Although one in five falls may require medical attention, less than one in 10 results in a fracture.
This review looked at the healthcare literature to establish which fall prevention interventions are effective for older people living in the community, and included 159 randomised controlled trials with 79,193 participants.  
Group and home-based exercise programmes, usually containing some balance and strength training exercises, effectively reduced falls, as did Tai Chi. Overall, exercise programmes aimed at reducing falls appear to reduce fractures.
Multifactorial interventions assess an individual's risk of falling, and then carry out treatment or arrange referrals to reduce the identified risks. Overall, current evidence shows that this type of intervention reduces the number of falls in older people living in the community but not the number of people falling during follow-up. These are complex interventions, and their effectiveness may be dependent on factors yet to be determined.  
Interventions to improve home safety appear to be effective, especially in people at higher risk of falling and when carried out by occupational therapists. An anti-slip shoe device worn in icy conditions can also reduce falls.
Taking vitamin D supplements does not appear to reduce falls in most community-dwelling older people, but may do so in those who have lower vitamin D levels in the blood before treatment.  
Some medications increase the risk of falling. Three trials in this review failed to reduce the number of falls by reviewing and adjusting medications. A fourth trial involving family physicians and their patients in medication review was effective in reducing falls. Gradual withdrawal of a particular type of drug for improving sleep, reducing anxiety, and treating depression (psychotropic medication) has been shown to reduce falls.
Cataract surgery reduces falls in women having the operation on the first affected eye. Insertion of a pacemaker can reduce falls in people with frequent falls associated with carotid sinus hypersensitivity, a condition which causes sudden changes in heart rate and blood pressure.
In people with disabling foot pain, the addition of footwear assessment, customised insoles, and foot and ankle exercises to regular podiatry reduced the number of falls but not the number of people falling.
The evidence relating to the provision of educational materials alone for preventing falls is inconclusive.

Interventions for preventing falls in older people living in the community

Background and Purpose. This study examined the sensitivity and specificity of the Timed Up & Go Test (TUG) under single-task versus dual-task conditions for identifying elderly individuals who are prone to falling. Subjects. Fifteen older adults with no history of falls (mean age578 years, SD56, range565‐ 85) and 15 older adults with a history of 2 or more falls in the previous 6 months (mean age586.2 years, SD56, range576 ‐95) participated. Methods. Time taken to complete the TUG under 3 conditions (TUG, TUG with a subtraction task [TUG cognitive], and TUG while carrying a full cup of water [TUG manual]) was measured. A multivariate analysis of variance and discriminant function and logistic regression analyses were performed. Results. The TUG was found to be a sensitive (sensitivity587%) and specific (specificity587%) measure for identifying elderly individuals who are prone to falls. For both groups of older adults, simultaneous performance of an additional task increased the time taken to complete the TUG, with the greatest effect in the older adults with a history of falls. The TUG scores with or without an additional task (cognitive or manual) were equivalent with respect to identifying fallers and nonfallers. Conclusions and Discussion. The results suggest that the TUG is a sensitive and specific measure for identifying communitydwelling adults who are at risk for falls. The ability to predict falls is not enhanced by adding a secondary task when performing the TUG. [Shumway-Cook A, Brauer S, Woollacott M. Predicting the probability for falls in community-dwelling older adults using the Timed Up & Go Test. Phys Ther. 2000;80:896 ‐903.]

/pdf/predicting-the-probability-for-falls-in-community-dwelling-y2rpgp6tsv.pdf

Predicting the probability for falls in community-dwelling older adults using the Timed Up & Go Test.

/pdf/chapter-4-european-guidelines-for-the-management-of-chronic-4lrtve55lo.pdf

Chapter 4. European guidelines for the management of chronic nonspecific low back pain.

Background Since falling is associated with serious morbidity among elderly people, we investigated whether the risk of falling could be reduced by modifying known risk factors. Methods We studied 301 men and women living in the community who were at least 70 years of age and who had at least one of the following risk factors for falling: postural hypotension; use of sedatives; use of at least four prescription medications; and impairment in arm or leg strength or range of motion, balance, ability to move safely from bed to chair or to the bathtub or toilet (transfer skills), or gait. These subjects were given either a combination of adjustment in their medications, behavioral instructions, and exercise programs aimed at modifying their risk factors (intervention group, 153 subjects) or usual health care plus social visits (control group, 148 subjects). Results During one year of follow-up, 35 percent of the intervention group fell, as compared with 47 percent of the control group (P = 0.04). The adjusted...

https://www.nejm.org/doi/pdf/10.1056/NEJM199409293311301

A multifactorial intervention to reduce the risk of falling among elderly people living in the community.

A randomized clinical trial of rotational manipulation was conducted on 95 patients with low back pain selected for (1) the absence of any contraindications for vertebral manipulation, (2) the absence of any psychosocial problems that might affect the outcome of treatment, (3) the absence of any previous experience with manipulative therapy, and (4) the presence of palpatory cues indicating that manipulation might be successful. Patients were randomly assigned to one of two groups: an experimental group receiving manipulation therapy and a control group receiving soft-tissue massage. Comparison of the two groups indicated that (1) patients who received manipulative treatment were much more likely to report immediate relief after the first treatment, and (2) at discharge, there was no significant difference between the two groups because both showed substantial improvement. ( JAMA 1981;245:1835-1838)

Spinal Manipulation for Low Back Pain

At 16 senior centers, we studied the effectiveness of exercise and cognitive-behavioral programs, compared with a discussion control program, in reducing falls and injuries among 230 older adults. After 1 year of the programs, we observed no significant difference in time to first fall. Even though a relatively high percentage (38.6%) suffered at least one fall, only 7.8% of these community-residing elderly required medical attention. Secondary outcome measures such as strength, balance, fear of falling, and perceived health did not significantly change.

Attempts to prevent falls and injury: a prospective community study.

https://www.archives-pmr.org/article/S0003-9993(00)90068-6/pdf

Interexaminer reliability of the palpation of trigger points in the trunk and lower limb muscles

Study design A randomized, assessor-blinded clinical trial was conducted. Objective To investigate the relative effectiveness of three manual treatments and back school for patients with subacute low back pain. Summary of background data Literature comparing the relative effectiveness of specific therapies for low back pain is limited. Methods Among the 5925 inquiries, 206 patients met the specific admission criteria, and 200 patients randomly received one of four treatments for 3 weeks: back school, joint manipulation, myofascial therapy, and combined joint manipulation and myofascial therapy. These patients received assessments at baseline, after 3 weeks of therapy, and 6 months after the completion of therapy. The primary outcomes were evaluated using visual analog pain scales and Roland-Morris activity scales. Results All four groups showed significant improvement in pain and activity scores after 3 weeks of care, but did not show further significant improvement at the 6-month follow-up assessment. No statistically significant between-group differences were found either at the 3-week or 6-month reassessments. Conclusions For subacute low back pain, combined joint manipulation and myofascial therapy was as effective as joint manipulation or myofascial therapy alone. Additionally, back school was as effective as three manual treatments.

Effectiveness of four conservative treatments for subacute low back pain: a randomized clinical trial.

Objective We sought to explore whether the elderly are high users of complementary and alternative medicine (CAM), and to determine which modalities they use We also sought to describe patterns and positive predictors of CAM use among 3 ethnically diverse groups of community-residing elderly Design A 7-page questionnaire was developed and translated into Spanish and Vietnamese Participants A population of 525 community-residing elderly completed personal interviews Results Two hundred and fifty-one respondents (478%) reported using CAM over the past year Dietary supplements (474%), chiropractic (163%), home remedies (159%), acupuncture (151%), and Oriental medicine (128%), were the most frequently cited therapies The majority of CAM users (624%) did not inform their physicians that they were using it, but 58% consulted their physician for the same problem for which they used CAM Family and friends were most relied upon for making the choice of therapy Among the 3 ethnic groups studied, Asians were higher users of acupuncture (28%) and Oriental medicine (31%), Hispanics were higher users of dietary supplements (56%), home remedies (25%), and curanderos (8%), while white non-Hispanics were higher users of chiropractic (42%), massage (20%), vitamins (20%), diet (17%), and psychospiritual (15%) modalities Pain was a higher indicator of CAM use among Asians, gastrointestinal problems and diabetes among Hispanics, and stress/fatigue and cardiovascular problems among white non-Hispanics Conclusion Findings indicated a high use of CAM among the elderly and emphasize the likelihood that elderly immigrants use those therapies with which they are familiar Modalities and conditions varied with the ethnicity of respondents

Jerome S. Tobis

Papers

Spinal Manipulation for Low Back Pain

Attempts to prevent falls and injury: a prospective community study.

Interexaminer reliability of the palpation of trigger points in the trunk and lower limb muscles

Effectiveness of four conservative treatments for subacute low back pain: a randomized clinical trial.

Use of complementary and alternative medicine among the ethnic elderly.