Experts Say Exercise Can Help Elderly Prevent Falls

Just Who are These Experts?

An article noticed in the Houston Chronicle provides some good information on the benefits of exercise in preventing falls and fall risk in older adults. The unfortunate thing is it features athletic trainers and orthopedists! Once again, PTs could lose an important part of our professional practice if we don’t step up to the plate, and quickly!

We have some great tools to assess both quantity and quantity of fall risk. The Berg Balance Score is an excellent tool to identify impairments related to fall risk and is an accurate tool to measure fall risk (+LR >5). Outpatient programs are the perfect place to assess fall risk, beginning with the question “Have you ever fallen?” People who have fallen have nearly a 100% chance of falling again. Interesting, this is a new quality measure that CMS is promoting to obtain a bonus of 1.5%.

A physical therapist is the best person to conduct the fall risk assessment and identify the Impairments that will drive the interventions. To be effective, these interventions need to be evidence-based, providing the appropriate intensity, specificity, and challenge to the appropriate system. In a quick Google search of PT and fall prevention, I found a news release from the CPTA that was a nice spot on the role of PTs in fall assessment and interventions. APTA also has some good resources regarding balance and falls including a brochure and a kit to conduct community fall risk screenings.

Advocate for your profession and those aging adults who don’t want to fall. PTs are the best thing to happen to older adults!

Dale Avers

Comments

[Selena Horner]

Clinically we have reimbursement issues for treatment of an elderly person who is at risk of falling. There isn't a convenient ICD-9 code (and sometimes there isn't any clinical documentation to support say "instability of gait" or "difficulty walking" because not every community-dwelling person at risk of falling has obvious impairments in which those ICD-9 codes apply). No supporting documentation to support those 2 ICD-9 codes could be perceived as fraudulent upcoding if audited. Then, for my situation, the common secondary insurance most have in my area, those ICD-9 codes are not recognized or payable codes.

As therapists we have the knowldege... we can probably impact the risk of falling in certain areas, especially if using literature to support our interventions - but being paid is a whole different story.

[Dale Avers]

Selena,
Have you tried the ICD code of weakness? Or Osteoarthritis? Poor balance (and thus fall risk) are linked to OA of the knee. A really great article about the reimbursement issue and the barriers (and solutions) to assessing for fall risk is: Tinetti ME et al. Fall-risk evalution and management: challenges in adopting geriatric care practices. Gerontologist. 2006;46(6):717-725. The authors state: "...although fall prevention per se is not covered, the evaluation and management of contributing conditions and the treatment of individuals who have already fallen are services covered at least to some extent." (p.721)

Another thought.....Why is it that personal trainers and athletic trainers are able to sell their services even though they are private pay - and PTs don't/won't? Is it that our profession is more linked to sickness/pathology rather than prevention and wellness? It's ironic that PT is one of the first things thought of AFTER a person has fallen, but not before. We need to change this perception. Why not through private pay mehcanisms? There is a preponderance of evidence that physical therapy successfully prevents falls. We need to practice this and then sell it!

Dale

[Selena Horner]

Dale, I'm in a rural community. The first question most of the patients with Medicare insurance asks me is whether services will be covered. The Medicare subscribers in my area are not paying athletic trainers or personal trainers anything because frankly we don't have those kinds of services available. Also, financially, most were farmers and prioritize their finances where prevention is a low priority.

ICD-9 of weakness would not be covered with the secondary insurances. I've been using osteoarthritis and crossing my fingers because the whole focus of my plan of care is fall risk and my goals are specifically aimed at reducing fall risk. I'd argue that technically the person does have osteoarthritis - how much of the population 65 and older doesn't?

And Dale, get this... you're going to be steaming! I was at our Michigan Spring Membership meeting. There were a couple of Geriatric proposals (whatever you call them) that were NOT well received! Of course, they all laughed at the fact that us professionals should be practicing national exercise guidelines and then, one delegate actually stated that "not everyone could exercise." AND there were a lot of heads agreeing with that statement! Of course I had to comically verbalize that pretty much everyone in our profession could at bare minimum do the Couch Potato Exercises. My opinion though, it is sad that we all know what we should be doing but a lot aren't (at least here in MI they aren't).

The other heated discussion revolved around Physical Therapists being included in the Welcoming Screening rolled out by Medicare! Hmmm... the arguments against physical therapists being involved revolved around patients feeling good about themselves and then learning and being overwhelmed with all their problems (from the initial physician visit). So, physical therapists would be dumping too much on the patient by also being included in the screening process! Correct me if I'm wrong, but hello, isn't there 6 months for the screening process to take place? Is it about how the patient "feels" or is it about improving the health of the patient? AND... if as a whole we are SO worried about how the patient will feel, well, geesh, schedule the physical therapy visit 2 months after the physician visit! AND... supposedly it has a "big brother" feel. Ummm... don't ask me what a fellow MI colleague was fearing. And one delegate actually stated that just because something sounded good doesn't mean that there couldn't be ill-effects! WHAT the heck is up with our profession???? Obviously, if Medicare is tagging falls as a quality indicator AND including it in the Welcome Screening - there is benefit for many - the subscriber on a personal level AND Medicare on a financial level and US on both the professional AND financial area. I'm lost as to what those ill-effects could be! Oh, trust me, I spoke my piece of mind... wishing you were on the other side of the room standing at the other microphone to persuade and challenge the thoughts in that room!

[Dale Avers]

Selena,
I think the MI therapists have hit upon the difference between personal trainers/athletic trainers and PTs. Personal trainers/athletic trainers know EVERYONE can benefit from exercise. Apparently PTs don't. AND AT are fit themselves! It doesn't bode well for our future, since exercise is one of the best evidece-supported interventions in our arsenal.

You are right, I am steaming. And I do wish I'd been at the MI meeting. Looks like I will need to attend the HOD to hear thse motions being heard on the floor. These motions came from the SOG Task Force on Exercise of which I'm a founding member. How can this profession move forward when we won't model fitness and don't believe ALL people (including ourselves) can benefit from supervised exercise?

Apparently this problem is deeper and more pervasive than knowledge. It sounds like agism is alive and well - which has been defined as "predujice against oneself" since we are all aging. I shudder to think what my old age will be like if I need a PT like the ones you describe! What can we do?

Dale

[Selena Horner]

What saddened me with the response to the the Medicare issues that were brought forward by the Geriatric section was the lack of a view of being a patient advocate and lack of realizing opportunity. We have a fabulous opportunity that we should fight to have become reality! Risk of falling is a real issue in that population. Osteoporosis is another factor. Diabetes is quite common. Medicare is targeting legitimate areas for concern - for the elderly, if their health declines it not only costs Medicare but it costs all of us as a society. I thought it was an excellent forward vision on the part of Medicare to think prevention. I'm also an athletic trainer and it is a whole lot easier to have an empty training room via programs implemented or conversing with coaches to reduce injuries versus saying nothing and fighting fire after fire by ignoring preventable injury. Who best to assess and evaluate in the areas of risk of falling, proper exercise for those at risk for osteoporosis than a physical therapist? Who best to take the lead and offer recommendations?

Poor Janet Downey - if you could have just seen her look of exasperation on her face as I would walk back up to the microphone to rebuttle the ridiculous fears/views of our colleagues on the impact we as physical therapists can and do have with the geriatric population (when we are extended the opportunity). The physicians do not have the time required to be thorough enough nor do they have the space in a treatment room to perform the task adequately. Asking "have you fallen in the last 12 months?" isn't enough. Nice job in meeting a quality indicator... but the next step is to figure out what to do about it!

I'm proud to be a member of the geriatric section - that section is very forward thinking. The section is a very strong advocate for the patient. What can we do? Well, I made a choice to share with you the opposition that may occur. By sharing opposition, that can assist in strengthening any arguments for the motions. :)

[Sean]

Selena,
What do you expect, it's Michigan, the cesspool of the world?
GO BUCKS!

[Taylor]

Following on the heels of the 'Blackberry Thumb' critics, our professional organization *absolutely* needs to put a face on our profession that is not trivial. If I was a senior concerned about my balance and a ATC approached me, I doubt I would refuse the help. And if the ortho surgeon who employ’s the ATC supports the idea—why the heck not! Dr. knows best, right?! On the other hand, are we as PTs inadequately demonstrating our proficiency as movement experts in such a way that allied health providers like ATCs can substitute our care?

I’m afraid to ask what this year’s PT Month educational topic is… Maybe organizers should look at the NATA’s website for ideas. I think if we have a whole month, we should be doing 1-topic per week highlighting different effective but overlooked specialty aspects of PT and tying it all together with Dr. Sahrmann’s idea of being movement specialist , say one week of wound care (ie. diabetic foot), geriatric (ie. fall risk), and women’s health (i.e. incontinence), neurovestibular (i.e BPPV), etc.

Good business move, NATA
http://www.nata.org/seniors/index.htm

[Jason Silvernail]

And what is the educational base of knowledge that prepares ATCs to treat geriatric patients?
Oh yeah...

[Dale Avers]

Thank you Taylor, for passing along this web site. I find it apalling! I've passed this on to the Section on Geriatric leadership - we must address this violation of ATC's scope of care for older adult's safety. Next, we need to work at incorporating wellness into our identity as physical therapists.

[Dale Avers]

Thank you Taylor, for passing along this web site. I find it apalling! I've passed this on to the Section on Geriatric leadership - we must address this violation of ATC's scope of practice to protect the safety of older adults. Next, we need to work at incorporating wellness into our identity as physical therapists.

[Dan Pinto]

I have just seen a puff piece on ATCs and Orthopods in the Rocky Mountain News and their quest to drastically reduce falls. PT is being attacked on all sides and I'm not convinced that our leadership isn't sleeping at the wheel. The EIM folks say the best is ahead of our profession, but not if we can't manage what we have. I haven't been this angry in a very long time. I'm losing heart, because our profession consistently drops the ball. It seems like we think as long as we put out the research people will come to us. Perception is reality folks! If ATCs are out there and saying this is what they do, a huge part of our population will think falls risk assessment and management is an "ATC thing" vs a "PT thing".

[Taylor]

Thanks for taking it to the next level, Dale. I hope prompt action is taken.

Dan,I am right there with you. I am only 3 years into the profession, yet readily growing disheartened by the 'outsourcing of skilled PT' to those who are willing, cheaper & cunning.

Between chiros, POPTs, podiatrists, massage "therapists", and now ATCs (am I missing anyone?) there is only so much I can take without feeling apathy in this situation. Where is this all headed???

[Dale Avers]

Everyone,
While I appreciate your desire to make our profession more responsive, I do have to remind all of us of my original post. Other folks are doing balance and falls interventions, osteoporosis interventions, wellness etc for older adults because WE AREN'T! There is a vacumm between what is needed/desired by older adults and what is available. How many of us address osteoporosis with evidence-based exercise (back extension strength as an example)? How many of us routinely screen for falls? If we don't, someone else will. Telling other "professions" to stop or having a fancier PR campaign isn't going to help if we aren't providing the service BETTER than anyone else.

A prominant leader in our profession and consummate professional said in response to this issue, "Every PT practice should be doing a screen for falls in a public facility 1-2x/year with media coverage (even small local newspapers). Getting us into the Intro to Medicare program is a goal so all seniors know that PTs are the people to see in this arena - in addition PT practices have to take their elderly beyond the immediacy of a swollen arthritic knee... We just need to simply be the best and the most vocal..." (unnamed as this was taken from a personal email).

The Section on Geriatrics Task Force for Exercise has been working for 2 years to prepare materials that will prepare PTs to be the THE exercise experts for older adults. But PTs will need to embrace this inforamtion and be willing to sell themselves. It really does begin with us.

As for the apathy, anger, and "loss of heart" you have expressed - DO SOMETHING! The leadership of APTA is elected by US (if you are a member). The House of Delegates is the policy making body of this profession made up of over 600 PTs representing their state. This is the place to express your opinions so they count. Get yourself elected to the House and make your opinion count. I guarentee you won't feel apathetic anymore! Alternatively, write a letter or two to Scott Ward the president of APTA. But most importantly, make sure you are practicing BETTER than anyone else. That is what will make the REAL difference. I don't care how good the ATC PR campaign is - if I'm getting better results than anyone else, I will be plenty busy as well as being perceived as the "expert."

We have a long way to go when PTs are not willing to practice the national guidelines for exercise or are afraid to screen for known risk factors because it "might make a person feel bad or discouraged." I think WE are the problem. And that is relatively easy to fix, beginning with ourselves. Let's do it!

Dale

[rowing clothing]

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