Which safety precaution should be taken for the patient with muscle weakness while walking?

Understanding the Problem

The changes that occur with aging can lead to problems with mobility, or a person’s ability to move around.  Mobility problems may be unsteadiness while walking, difficulty getting in and out of a chair, or falls. There are common conditions in older people that can contribute to mobility problems, such as muscle weakness, joint problems, pain, disease, and neurological (brain and nervous system) difficulties. Sometimes several mild problems occur at one time and combine to seriously affect mobility.

The number one mobility problem that older people experience is falls

Falls result in broken bones, bruises, and fear of falling. Older bones break more easily than younger bones and they heal less quickly and not as completely. If a hip is fractured, canes, walkers, or wheelchairs might be needed permanently. Falls are a major cause of injury and death, so prevention is important.

When an older person falls, but does not suffer serious injury, he or she might still have difficulty getting up from the fall.

• If the person is in serious pain, or has clearly suffered an injury, wait for help to arrive.
• If he or she has not been seriously injured but is having difficulty moving and getting up, he or she may be able to crawl to a solid chair and use it as a support in getting up.
• If the person is lying on his or her back, instruct them to first roll onto one side and then they can try to move from a side-lying position to a crawling position on all fours .
• If the person needs your help to get up, lift him or her with your arms by bending your legs—do not use your back muscles to lift the person. (Bend at your knees and push up with your legs.) Once the person is in an all fours position, instruct him or her to crawl towards the seat of the chair and lift the trunk of his or her body up with hands on the chair; he or she should then bring one foot up into half-kneeling position and from there either sit into the chair or stand up. If the person can't do this, you will need to call for help. 

An injury from a fall may result in limited or reduced mobility or even bed rest. Unfortunately, this can worsen existing medical illnesses and lead to new ones such as circulatory problems including blood clots in the legs, further loss of strength, pressure ulcers, or pneumonia.

Encourage physical activity

When older people have falls—even if the fall isn't serious—they often become fearful of falling again. This can lead to inactivity that can cause additional health problems. One of the most important things you can do to help someone with mobility problems and fear of falling is to encourage physical activity. Even a little activity strengthens bones and muscles, improves steadiness when walking, and helps prevent fractures. If the older person is afraid of falling, suggest using a cane or a walker. Sometimes older people are afraid they will not be able to get up from a fall. It is important to learn how to get up from a fall before the fall occurs. In some cases it can be helpful for the older person to practice getting up from the floor. A physical therapist can help with teaching a person how to do this. In addition to helping the older person stay active, you can help prevent falls and fractures by doing a home safety check and correcting conditions that could lead to falls.

Tell the healthcare provider

Tell the healthcare provider about mobility problems of the person you are caring for and especially mention any falls, since they can be caused by medical conditions. Drowsiness or distraction can lead to falls.  Drowsiness or distraction can be cause by worry, alcohol, or medicines such as prescription, non-prescription, or herbal or other remedies. Certain medical conditions such as poor eyesight and diseases like arthritis can also affect mobility. The risk of falling can often be reduced if the medical condition is diagnosed and treated.

Your goals are to:

• Prevent falls by reducing hazards in the home
• Encourage activity/exercise to improve mobility and strength
• Report any recurrent falls or near falls to the healthcare provider for a medical evaluation

Click on each of the topics below to read more.

When To Get Professional Help

Call the healthcare provider immediately or go to the emergency room if any of these occur

The older person has experienced a major fall

When older people experience a hard fall, such as when their legs suddenly move out from under them and they land forcefully on their back, side, or head, it is important that they be evaluated as soon as possible. Call the healthcare provider immediately in this case. Even if the older person does not appear to be injured, make an appointment with the healthcare provider for an evaluation.

Loss of consciousness after a fall

Possible causes include medicines, herbal or other remedies, a stroke, a heart problem, diabetes, seizures, dehydration, or a head injury during the fall. If a person remains unconscious or does not recover quickly, call 911.

Complaints of pain after a fall, especially in the hip or in the groin

This could mean a fractured hip or pelvis.

There are symptoms such as fever, coughing, or difficulty breathing at the time of the fall

Falls can sometimes be a sign of illnesses such as heart disease, pneumonia, or other infections.

Call the healthcare provider during office hours to discuss the following problems

Recurrent falls or tripping for no apparent reason

This could indicate Parkinson's disease, dementia, poor eyesight, or could be a result of medicines.

Obvious problems with gait and balance such as a limp or dragging a foot

This could be caused by thyroid disease, nerve injury, a stroke, Parkinson's disease, or other problems in the joints, bones, muscles, spinal column, or brain.

Decreases in activity level or inability to walk usual distances

These could be caused by heart disease or a lung condition such as emphysema or infection, a stroke, depression, circulatory problems, or over-medication with sedatives or tranquillizers. It is important to find the reason for the problem and, when possible, treat it.

Feeling lightheaded or dizzy

High blood pressure, depression, diabetes, heart disease, chronic pain, and insomnia are common problems among older people. Many of the medicines used to treat these conditions can make a person lightheaded, dizzy, or less alert, especially at night. This can increase the risk of falling and fracturing a bone.

If you are unable to help the person to move around

The healthcare provider can arrange for a physical therapist, social worker, or visiting nurse to show you how to help and, if necessary, arrange for outside assistance or medical equipment such as a wheelchair or walker.

Know the following information before calling the healthcare provider

A useful acronym for remembering the important parts to a fall history is SPLAT:

Symptoms

• Did the person report pain or discomfort after the fall

• Did the person lose consciousness after the fall?

• What medicines is the person taking? Make a list of their prescription, non-prescription, herbal and other remedies.

• Did the person complain of lightheadedness, dizziness, weakness, chest pain, or palpitations prior to the fall?

• Does the person have a history of heart disease, high blood pressure, diabetes, stroke, Parkinson's disease, memory loss?

Previous falls

• Has this person fallen more than once in the last few weeks?

Location

• Where did the fall occur?

Activity

• What was the person doing at the time of the fall?

Time

• What time of day did the fall occur? How long ago?

What You Can Do To Help

Identify fall hazards in the home and eliminate them

Many older people fall because of an unsafe environment at home. Use the Preventing Serious Falls tip sheet to help make sure the older person's environment is as safe as possible.

Pay special attention to safety proofing the bathroom since this is where most falls occur:

• Put rubber appliqués or rubber mats on the tub bottom.
• Tubs and showers are easier to get into if side rails are added or if handrails are installed onto shower walls. A plastic chair or stool (available at a hardware or garden store) can be used in the shower, allowing the older person to sit and wash feet and legs more easily.
• Toilet seats can be raised and side rails attached to the toilet. In addition, special toilets that have a higher seat than standard ones can be installed by a plumber.

These safety items can be purchased at medical equipment stores or through their catalogs.

Ask the nurse or therapist for help

Visiting nurses, occupational therapists, or physical therapists that come to the home can identify fall hazards and make recommendations to improve safety. They can help you conduct your own home safety check or do one for you.

Help the older person stay physically active

A regular program of exercise can strengthen muscles and improve flexibility. With increased strength and balance, an older person is better able to maneuver and avoid a potential fall. Some simple exercises that older people can do are included at the end of this section. Ask the healthcare provider if these exercises would be beneficial for the person you are caring for.

Check with local hospitals, senior centers, and community centers to see if they offer fall prevention, exercise, or walking programs for older people

Ask the healthcare provider about walking aids

A large selection of canes and walkers is available that make mobility easier and safer. Older people who use a cane should be encouraged to carry it with them at all times. If they are even a little bit unsteady on their feet, they should use a cane or walker. Some of the newer designs of walkers even come with a built-in seat, which allows the person to sit and rest when tired. Although canes and walkers can be purchased at some drug stores, it is a good idea to check with a healthcare provider to find out what type of cane or walker the older person needs. A physical therapist will make sure the cane or walker are adjusted to the right height and can teach the older person how to use it.

Ask the healthcare provider to check all medicines being taken

This includes all prescription, non-prescription and any herbal remedies.  Throw out all outdated medicines and, with the healthcare provider's assistance, try to adjust your medicine plan to make it as simple as possible. Have the older person stop taking multiple medicines that act similarly to each other.

Make sure vision and hearing are tested regularly and properly corrected

Seeing poorly or not hearing well can be a cause of mobility problems and can lead to falls. Make sure the older person is especially careful just after getting new bifocal or tri-focal eyeglasses. If the ground is out of focus on looking down through unfamiliar lenses, the chances of falling are increased.

Make sure proper footwear is worn

Sturdy, well-fitted, low-heeled shoes with wide, nonskid (rubber) soles should be worn. A walking shoe with good arch support and heel counter (rear-most part of the shoe) is recommended. Avoid slippers (unless they have non-slip soles), clogs, or sandals that can come off easily. Avoid long shoe laces, or pants that are too long which can cause tripping.

If the older person is afraid of falling, discuss these fears

People with a fear of falling will need to practice doing the things they are afraid of. Otherwise, they will not get the exercise they need and this can lead to other medical conditions such as weakened muscles and bones or blood clots in the legs. Set small goals and gradually build up the activity level. Build confidence by giving praise and encouragement, then gradually encourage being active when alone.

Create opportunities for socializing

Look for community activities that will keep the older person mobile.

Don't help the older person too much

Resist the temptation to do everything for the older person because you are afraid "something might happen." Older people need to stay active and like to remain independent.

Carrying Out and Adjusting Your Plan

Problems you might have carrying out your plan

"I don't need to do special exercises. I get enough exercise just from walking."

Walking is good exercise, but the healthcare provider or physical therapist can also prescribe special exercises to prevent problems that can lead to falls. For example, a physical therapist might recommend special posture exercises that will strengthen and improve balance. A physical therapist can sometimes identify the underlying cause for balance and mobility problems and recommend specific balance-improving exercises that will reduce the risk for falling. Unless specific exercises are performed to address such problems, the problems will continue.

"It's normal for older people to have decreased mobility."

Significant loss of mobility is not part of normal aging. In the healthy older person it may be  more to do with inactivity. With regular exercise, strength and flexibility can be preserved for a longer time.

"I'm afraid she will fall again."

A certain amount of fear and respect for hazards is healthy, but too much concern may end up restricting mobility, which makes the likelihood of falling greater. To overcome this obstacle, be creative. For example, it might be easier for the older person to overcome the fear of falling by simply being with other people. Help the older person find a friend to walk with or an exercise program to join. Investigate "mall walking" if the climate is very hot in summer or cold in winter. In many places groups of seniors meet daily and walk the mall. Some shopping malls even open an hour or so early to encourage this activity. Many social contacts are made when this occurs.

"I don't need a walker."

Walkers can prevent falls by making mobility easier and safer. Using a walker allows the older person to continue to walk independently and not be confined to a wheelchair or admitted to a nursing home. Say to the person, "Isn't it worth it to use a walker?"

"I can't afford to install the recommended safety device."

Most safety changes are easy to make and are not expensive. There are volunteer organizations that can help you buy and install safety equipment. If money is a problem, ask to talk to a social worker who will advise you about financial help that may be available.

Think of other problems you might have carrying out your plan

What other problems could get in the way of doing the things suggested in this section? For example, will the older person cooperate? Will other people help? How will you explain your needs to other people? Do you have the time and energy to carry out this plan?

Checking on Progress

Be realistic about expecting change

A large part of your plan will be prevention. Don't be discouraged if you do not see an increased level of activity. If the older person is maintaining activity and no falls are occurring, your plan is working because you are preventing the problem from getting worse.

If mobility problems are getting worse, ask the healthcare provider for help. Tell them what you have done and what the results have been.

A Few Words about Wheelchairs

If the older person cannot get around by foot anymore and must use a wheelchair, exercises are still very important to keep bones strong and joints flexible. The old saying still holds true: "If you don't use it, you lose it." Not all older people need to use wheelchairs full time. It can be a good idea to use a wheelchair for long distances in order to save time and to avoid fatigue. Depending on the needs of the person who will use the wheelchair, the healthcare provider or physical therapist will be able to make suggestions for the type of wheelchair to use, what features it should have, and how to use it safely.

The wheelchair should be a good fit

• A wheelchair that is too wide can cause bad posture.
• A wheelchair that is too narrow can cause skin breakdown from rubbing against the frame of the chair.
• At the most, the person should have one-inch clearance on each side of the chair.
• When sitting in the chair, weight should be equally distributed and the trunk and limbs should be balanced.
• Having two to three inches between the front of the seat and the knee joint helps proper weight distribution and prevents cutting off circulation to the legs, or pressing on nerves to the legs and feet.
• Leg rests should clear the floor by two inches.
• The chair size should change if there is significant weight loss or gain.
• If the older person will be in the chair most of the day, consider getting good cushions. 
• Older people can develop tendon and joint contractures when they are in a wheelchair for long periods of time. This can mean the muscles do not stretch, and can become weak. To avoid this, he or she should lie on the stomach or back with legs and back fully extended for periods of time each day. Gentle stretching exercises while in this position are helpful.

Consider where the chair will be used

• If you live in a mobile home, you may need a chair with a narrower frame.
• A lightweight chair is easier to take in and out of a car and is best for a person who travels often.
• Wheelchairs can be customized and there are many accessories available. Armrests can be made to fit under a desk, leg rests can be detachable or swing away, and lap boards and trays can be used for meals.
• There are two types of wheels for wheelchairs: pneumatic and solid. Pneumatic wheels give a better ride and may be necessary for a very frail older person. This type of wheel requires maintenance. The solid wheels are fine if the chair is being used only in the home and not for travel. The maintenance for this wheel type is very low.

Safety precautions

• Seat belts should be worn whenever the wheelchair is in motion.
• Keep the chair in good working order. Check the brakes, air in tires, and upholstery. Oil the metal joints to insure that they work smoothly and to prevent rust.
• When assisting someone in a wheelchair up or down a curb, first tilt the chair back on its large back wheels. Then, while balancing the chair on the large wheels, slowly lower the chair down over a curb. When going up a curb, turn the chair around (backwards) so the person in the chair is facing away from the curb. Again, slightly tilt the chair back on its large back wheels. Pull the chair up over the curb while balancing the chair on the back wheels.
• When putting a wheelchair into the trunk or back seat of a car or van, remove any parts that are detachable such as the cushions and leg rests. Then, fold the chair and place it on its side in the trunk, or upright if you are putting it in the back seat of a car or van. Remember to bend your legs, not your back, when lifting any heavy object.

Exercises for Persons 55 Years Old and Older

These exercises are to be started gradually. Work at your own pace and level of ability. Do these exercises daily if possible, but at least three times weekly.

• Start with five or ten repetitions; do fewer if necessary or more if you can.
• Slowly increase by adding two to four or more repetitions every five to ten days.
• Progress until you can do approximately 15 to 25 repetitions of each exercise.

High Step

Purpose: To increase hip and leg strength and balance
Hold on to a chair for balance; stand up straight. Raise one foot off the floor so that your knee is as high as your hip. Reverse legs. Try not to lean on the chair too much. As you get stronger, you may be able to raise your leg higher, hold for count of 5 (less if necessary), and decrease amount of leaning on chair.

Side Step

Purpose: To increase hip and leg strength and balance
Hold on to chair for balance; stand up straight. Move one leg out to your side and hold it in the air. Don't bend at the waist. Hold leg for 5 seconds (or less if necessary). Reverse legs. At first, you may be unable to hold your leg in the air. If so, simply move your foot out to the side.

Stand Up -- Sit Down

Purpose: To improve strength, balance, coordination, and joint motion
This is the key to being independent. Simply stand up, then sit down. To do this, you must get your feet under the front of the chair. Move your center of gravity forward and then up. If necessary, use the chair's armrest. As you get stronger, decrease the amount of push that you need from your arms.

Shoulder Shrug

Purpose: To strengthen back, stretch chest muscles, and improve posture
Sit up or stand up straight. Shrug your shoulders up high and release. Pull your shoulders back. You should feel your shoulder blades pull together.

Cervical Range of Motion

Purpose: To improve posture, balance, and range of motion
Sit up or stand up, head erect but not forward.
Turn your chin to your left shoulder and reverse to the right.
Lean your ear to your left shoulder and reverse to the right.
Lightly place your finger on your chin and push your chin backward. Do not roll your head backward as if looking up at the ceiling.

Toe, Heel, and Leg Rises

Purpose: To improve ankle strength for balance
While holding on to the back of a chair or countertop, stand straight and tall, with your knees slightly bent and your toes pointed straight ahead. Line your knees up over the point of your shoes. Look straight ahead. Keep your chin tucked and your shoulder blades back. Tighten your stomach muscles.

• First, rise up on your toes and then lower yourself down.
• Second, raise the toes and front part of your feet while shifting weight to the heel.
• Third, lift one leg and hold for 10-30 seconds.
• Lower and repeat with other side.
• Slowly and carefully repeat each exercise 3-5 times.

Eyes-Closed Balance Exercises

Purpose: To improve balance
Focus your eyes on a target 10-20 feet away while you change from sitting to standing and back again with your eyes OPEN. Make sure that you land softly when you sit. Repeat with your eyes CLOSED. (Have a spotter in the case you lose balance!)

As you do this exercise, feel the position of your body as you move. Be sure that you keep your weight forward on the front of your feet, knees apart, chest forward, and spine erect.

Half-Circle Sway

Purpose: To improve balance
If you have experienced falls or problems with balance, get permission from a physical therapist before doing this exercise.

Stand with your feet shoulder distance apart. Hold onto a counter or sturdy table for safety. Lean forward slowly from the ankles without bending the hips so that 70% of your body weight is on the balls of your feet.

• Return to neutral standing position.
• Lean slowly to the left until 70% of your weight is on the left side of your feet.
• Return to neutral standing position.
• Lean slowly to the right until 70% of your weight is on the right side of your fee.
• Return to neutral standing position.
• Now put it all together making graceful half- Circle sways from left to center to right and back again.

Walk, Walk, Walk

Purpose: To enhance overall health of muscles, bones, joints, circulation, heart, lungs, digestion, bowels, and mind.

Walk at whatever level of ability you have. If you can walk only 50 feet, start at that level and try to increase the distance and improve your gait speed. Avoid stops and starts. If you are walking longer distances, such as a half-mile in 5 to 10 minutes, do a little stretching before starting. When finishing your walk, cool down by walking slowly, stretching, and doing a few of these exercises or your favorite ones.

If you need help getting started or if you have any concerns about your health, show these exercises to your physician or nurse.

Adapted from Border B and Wagner M. Functional Performance in Older Adults. FA Davis, Philadelphia, PA:1994, pp. 60-61 and "What You Need To Know About Balance and Falls. A Physical Therapist's Perspective," American Physical Therapy Association, Alexandria, VA: 1998.