All about falls

Every time you take a tumble, realize it's just a chance to bounce back.

A fall is defined as an event which results in a person coming to rest inadvertently on the ground or floor or other lower level. Falling over is something that happens at all stages of life, but why is it that when you hit a certain age the language of falling over shifts to “had a fall”? This is due to how falling affects people across the lifespan, as children tend to bounce but older adults risk more significant injuries.

Why do falls matter:

-          238,005 hospitalisations due to falls in AUS in 2022-2023.

-          43.4% of all injury hospitalisations in AUS in 2022-2023.

-          6,378 deaths in 2022-2023.

-          Most common body parts injured were

o   Head and neck (28.1%)

o   Hip and femur (26.2%)

o   Shoulder and upper arm (22.7%)

-          Females had higher rates of falls hospitalisations (772.4 per 100,000), but males had higher rates of deaths caused by falls (14.8 deaths per 100,000)

-          Females were more likely to fall on stairs or steps, from a bed, or from a chair, while males were more likely to fall from a building, a tree, a ladder, or using objects such as roller skates or scooters.

-          Australians aged 65 and over were almost 12 times more likely to be injured in a fall than adults aged 25-44

Common causes of falls:

-          Medical conditions

o   e.g. Parkinsons disease, peripheral neuropathy, postural hypotension

-          Medication side effects

o   Drowsiness, vision changes, dizziness, confusion, blood pressure changes etc.

-          Taking more than 10 different medications

o   Due to the interactions between different medications, and the combined effect these medications may have on cognition drowsiness, or vision etc.

-          Foot problems, including poor footwear.

-          Reduced muscle strength

o   A natural change from aging (though this can be slowed!)

-          Slowed reaction time

o   A natural change from aging (though this can be slowed!)

-          Poor vision

-          Incontinence

o   Due to a rush to get to the toilet and associated weakness of the leg and trunk muscles.

-          Environmental causes

o   Rugs, walkers out of reach, loose floorboards, cables, clutter, and even pets!

What tools are there predict falls risk?

Five times Sit to Stand: this is a standardised test used to measure how a person transfers from a sitting to standing position (and vice versa). It is a useful quick screen to assess lower limb strength, speed, balance, and coordination. This test has been used in a variety of population groups (seniors, Parkinson’s disease, stroke etc.) and can be used to assess how likely a person is to fall within 12 months. For example, a healthy adult aged 70-79 years should achieve between 6.9s and 13.1s, with a score above 15s indicating an increased risk of falling.

FRAT (Falls risk assessment tool): A 3-part tool that comprises of a falls risk status, a risk factor checklist, and an action plan, developed by Peninsula Health Victoria. This tool is typically administered by a medical practitioner such as a GP or nurse, though some sections can be done without their input. Cognitive status (Part 1, section 4) involves the Abbreviated Mental Test Score, used to assess for delirium or dementia risk, with low scores indicating a need for further cognitive assessment.

These are just two tools out of the hundreds available, if you want to know more feel free to ask your Physiotherapist, Exercise physiologist, or GP.

Can you change your falls risk?

YES!

Falls risk can be reduced by addressing the factors that increase your risk. Some factors can be changed, and some cannot. For example, you can’t change your age, but you can change your vision by using glasses. Speaking to your Physiotherapist or GP about reducing your risk is a helpful way to pinpoint areas to work on.

Participation in physical activity is a great way to reduce your falls risk. Activities such as tai chi, yoga, Pilates, hydrotherapy (or aquarobics), or just general strength and conditioning all have been demonstrated to improve strength, balance, reaction times, and even help with cognition and memory through social engagement. Here at Healesville Physiotherapy and Sports Medicine we run a Falls and Balance class twice weekly under a physiotherapist, or Eastern Health run a 10 week Falls clinic which involves a variety of healthcare disciplines to help get to the root cause of your falling (See link in references for more information). At the end of the day, the best exercise is the one you will consistently do so pick something you enjoy doing!

According to the World Health Organisation, all adults should be aiming to get 150-300 minutes of low to moderate exercise, or 75-150 minutes of moderate to vigorous exercise, AND 1-2 sessions of resistance training per week. This should be a lifelong goal to keep you healthy and active throughout your lifespan.

Help, I’ve fallen! How do I get off the floor?

Here is our handy flow chart of how to safely get off the floor without the assistance of another person. This is difficult and requires a lot of strength, so some people will need assistance either from a bystander or from ambulance staff. This should only be attempted if there are no obvious injuries such as fractures or head wounds.

Version 1: No equipment

Step 1: Take a moment to take some slow deep breaths. Mentally scan your body for any injuries, if there are any areas of significant pain or bleeding, have someone call 000 and do not continue to rise.

Step 2: Bend one leg.

Step 3: Push the bent leg into the floor and bring your arm across your body as you let your knee drop across, this will help roll you into side lying.

Step 4: From side lying, start to push with both arms into half sitting.

Step 5: Continue to roll from half sitting, onto hands and knees.

Step 6: From hands and knees, bring one leg under your body and push your torso upwards with your arms and core. This will bring you into a lunge.

Step 7: Push your arms into your legs (or the floor if you are flexible enough) and push through both legs to start to rise. Continue pushing through this position to finish in standing.

Version 2: Using a chair

Step 1: Take a moment to take some slow deep breaths. Mentally scan your body for any injuries, if there are any areas of significant pain or bleeding, have someone call 000 and do not continue to rise.

Step 2: Bend one leg.

Step 3: Push the bent leg into the floor and bring your arm across your body as you let your knee drop across, this will help roll you into side lying.

Step 4: From side lying, start to push with both arms into half sitting.

Step 5: Continue to roll from half sitting, onto hands and knees.

Step 6: On hands and knees, crawl towards a chair, couch, bed, or other supportive surface.

Step 7: Place both hands on the chair seat (or arm rests as required).

Step 8: Push down through your arms into the chair seat, and bring one leg in front into a lunge position.

Step 9: Continue to push firmly through your arms and leg, as you bring the other leg up to stand. From this position you can stand, or use the back of the chair to help lift your torso.

References:

https://www.who.int/news-room/fact-sheets/detail/falls

https://www.aihw.gov.au/reports/injury/falls#types-of-falls

https://www.nhsinform.scot/healthy-living/preventing-falls/causes-of-falls/

https://www.sralab.org/rehabilitation-measures/five-times-sit-stand-test

Buatois, S., Miljkovic, D., et al. (2008). "Five times sit to stand test is a predictor of recurrent falls in healthy community-living subjects aged 65 and older." J Am Geriatr Soc 56(8): 1575-1577 https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/j.1532-5415.2008.01777.x

https://www.health.vic.gov.au/publications/falls-risk-assessment-tool-frat

https://www.easternhealth.org.au/service/falls-and-balance-clinic/

Growing pains

Growing pains, what a pain!

During periods of significant growth, some children experience an aching or throbbing pain the legs. Often, there is no obvious cause for this pain and it is attributed to muscle tightness or weakness, or overuse activities. This occurs most commonly between the ages of 3-5 and 8-11 years, but can occur outside of these age brackets depending on when your child has a growth spurt.

When should you seek help:

While most “growing pain” conditions are self-limiting and self-resolving, some conditions can need some further management. You should consult with your child’s physiotherapist or general practitioner if you are concerned about your child’s pain, want some further information about management strategies, or if your child’s pain is:

-          Persistent

-          Disturbing their sleep

-          Impacting their activities

-          Impacting their movement

-          Associated with symptoms such as fever, fatigue, redness, tenderness, rash, or loss of appetite.

Conditions that are more than just growing pains:

Some conditions early stages appear very similar to growing pains, and treatment can often be delayed as a result. 

Medial tibial stress syndrome:

Pain occurring at the front of the shin, where the muscles of the foot and ankle attach to the shin bone (tibia). MTSS is often lumped into the group of conditions known as “shin splints” which encompasses any pain at the front of the shin. MTSS is more common in runners, and jumping athletes, due to the loading that goes through the shins during these activities. It is also more common in females. In severe cases, this bony stress can progress to stress fractures.

Sever’s disease:

Pain occurring at the back of the heel, where the Achilles tendon attaches to the calcaneus (heel bone). Sever’s occurs when the developing bone and growth plates are exposed to high load repetitive forces, such as running or jumping. Over time, the irritation to the bony attachment point results in a bony callus formation, or bony lump where the tendon attaches. In rare, severe cases, high force can cause the Achilles tendon to fracture the bony attachment site (avulsion).

Osgood Schlatter’s:

Pain occurring just below the kneecap, where the patella tendon attaches to the top of the shin bone (tibia). The quadricep muscles are an extremely powerful group of muscles that attach to bone via the patella tendon. Like Severs, when the bony attachment site is irritated over a long period of time, a bony callus begins to form at the base of the patella tendon causing pain. This condition is more common in males, runners, impact sports, and sports that involve significant use of the quadricep muscles. In rare, severe cases, high force can cause the patella tendon to fracture the bony attachment site (avulsion).

How does physiotherapy fit into management?

 Physiotherapists perform thorough examinations to determine the specific diagnosis, and root cause of pain. Sometimes, this involves getting scans such as ultrasound, x-ray, or MRI’s. Management initially targets pain modification, which can consist of activity modifications or rest, heat/ice modalities, soft tissue release (e.g. stretching, massage, dry needling in older children or adults), and/or taping or bracing/orthotics. Once the pain has started to settle, management shifts to gradually reloading the tissues to return to normal function, through specific strengthening programs and return to sport programs.

In some cases, physiotherapy alone isn’t sufficient in managing the condition so other interventions such as medical/pharmacology management (through general practitioners or sports physicians) or orthotics (podiatry) are explored.

Can my child still do sports with these conditions?

Participation in physical activity is important for a growing mind and body, and there are great psychological and social benefits to participating in sports. Sometimes, a period of rest is required, but where possible cross training should occur so children can stay active. It is important that your child’s coach/trainer/PE teacher is aware of their condition, and their capabilities and limitations while in the healing stages. Physiotherapist can assist by giving detailed sport specific instructions of suitable participation during the recovery process.

It is important to recognise that most children participate in sports and activities without any pain, and that some children who develop pain don’t participate in sports at all. Finding the root cause is important as often pain in sports is just a symptom!

References:

Mayo clinic: growing pains. https://www.mayoclinic.org/diseases-conditions/growing-pains/symptoms-causes/syc-20354349

McClure CJ, Oh R. Medial Tibial Stress Syndrome. [Updated 2023 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK538479/

Fares, M.; Salhab H.; Khachfe, H.; Fares, J.; Haidar, R.; Musharrafieh, U. Sever’s disease of the paediatric population: clinical, pathologic, and therapeutic considerations. Clinical Medicine and Research. 2021, 19(3): 132-137. https://www.clinmedres.org/content/19/3/132.full

Lucenti, L.; Sapienza, M.; Caldaci, A.; Cristo, C.d.; Testa, G.; Pavone, V. The Etiology and Risk Factors of Osgood–Schlatter Disease: A Systematic Review. Children 2022, 9, 826. https://doi.org/10.3390/children9060826

Physiotherapy for children

Physiotherapy for children

Children are resilient and more often than not will bounce back from injury or illness without needing intervention. Some conditions can benefit from physiotherapy, especially in the acute stages, or for chronic conditions that aren’t resolving on their own. In chronic or lifelong conditions, physiotherapists can be an integral part of the medical and allied health team who work together to get optimal function and quality of life. For some acute conditions, just like an adult with a broken bone, kids can need some help to get back to the things they love.

Musculoskeletal physiotherapists:

Musculoskeletal physiotherapists are the bread and butter of physiotherapy, working across the lifespan and entire body. While most of their work tends to be in adults, they are also involved in the assessment and treatment of musculoskeletal problems in children. This can include:

-          acute injury e.g.

o   fracture management

o   sprains and strains

o   concussion

-          chronic injuries or conditions e.g

o   overuse injuries

o   Rehabilitation following prolonged hospitalisation or deconditioning

-          developmental conditions

o   scoliosis or Scheuermann’s disease

o   “growing pains” such as Severs disease, Osgood Schlatter’s, or shin splints.

-          Medical/genetic conditions

o   Cystic fibrosis

o   hypermobility conditions

o   Cerebral palsy

Paediatric physiotherapists:

Paediatric physiotherapists only work with children, and tend to be more specialised in some areas such as babies, neurological conditions, and developmental conditions than a musculoskeletal physiotherapist. Common conditions they work with include:

-          Chronic illness or injury e.g.

o   Cancer rehabilitation

o   Amputations (or limb differences from birth)

-          Developmental or progressive conditions

o   scoliosis or Scheuermann’s disease

o   Congenital Talipes Equina Varus (club foot)

o   Muscular dystrophy

-          Medical/genetic conditions

o   Cystic fibrosis

o   hypermobility conditions

o   Cerebral palsy

o   Autism spectrum disorders

Which type of physiotherapist should I choose?

For acute injuries, sporting injuries, or chronic injuries a general musculoskeletal physiotherapist will meet your child’s needs.

For chronic medical conditions, developmental conditions, or early life conditions (i.e. babies) a paediatric physiotherapist will be best suited for your child’s needs.

If in doubt, all physiotherapists can get your child started on the rehabilitation journey, and if required can refer you onto someone more suitable. Paediatric physiotherapists can be hard to access though due to their specialisation, so sometimes you need to travel to get access. If distance is an issue, you can work with both so that the musculoskeletal physio can handle the day to day rehab, and the paediatric physio can manage the overall program every few months.

How will you get my child to engage in rehabilitation?

Fun! Children respond best when things can be fun, so a lot of our specific exercises are transformed into fun games to help them stay interested and active in participating. What may look like a simple game of tiggy is actually a great vessel for lower limb strengthening, cardiovascular endurance, and coordination!

Each child is different (and at different stages of life they may like different things) so programs are highly individualised and tailored to suit your child’s needs.

Acute Injury Management: PEACE and LOVE

Acute Injury Management:

How many times have you been told to RICE, or Rest, Ice, Compress and Elevate, after rolling an ankle, spraining your knee or straining your calf? This was the protocol after research conducted in 1978, the same year the original Grease movie was released! Times have changed and research has evolved since then and the current protocol for an acute injury management includes PEACE and LOVE. 

Immediately after an acute injury remember:  PEACE

P - Protection 

Unload or restrict the movement of the injured area for 1-3 days to ensure no further damage is done to the injury. 

E - Elevation 

Elevate the injured limb above the level of the heart to promote fluid draining out of the area to avoid excess swelling. 

A - Avoid - anti inflammations 

In the early stages, inflammation can help to repair injured tissue and is a normal part of the healing process. Tissue healing can be impacted negatively restricting inflammation via medication. 

C - Compression 

Taping or bandages to reduce swelling inside the joint and tissue haemorrhaging can improve quality of life and level of function. 

E - Education 

Education from a physiotherapist on active recovery approaches, and realistic expectations.

After a few days of an initial injury, remember:  LOVE

L - Load

Gradually increase your load until you return to normal activities allows for adaptations in muscles, tendons and ligaments to promote repair, remodelling and improving tolerance. Pain should not be more than a 3-4/10 during active rehabilitation. 

O - Optimism

Having a positive approach to rehabilitation and optimistic outlook is associated with better patient outcomes and a better prognosis. 

V - Vascularisation

Pain free aerobic exercise (cycling, swimming, walking, rowing, ski erg) should be started a few days after sustaining an acute injury to promote blood flow to increase tissue healing, reduce pain, increase motivation and promote return to work. 

E - Exercise

Completing exercises to rehabilitate an injury reduces the chances of suffering recurrent injuries. Exercises help to restore strength, range of motion and proprioception. Pain does not mean that you are creating further damage, however if the exercises are causing a level of pain above a 3-4/10 they should be modified. 

Practising PEACE and LOVE can help to reduce pain and promote tissue healing allowing for an earlier return to everyday activities such as return to work or return to sport! If you have an acute injury, come in and see one of our expert physiotherapists at Healesville Physio and Sports Medicine. 

Dubois, B., & Esculier, J.-F. (2020). Soft-tissue injuries simply need PEACE and LOVE. British Journal of Sports Medicine, 54(2), 72- 73. https://doi.org/10.1136/bjsports-2019-101253

Mirkin G., Hoffman M. (1978) The sports medicine book. 1st edition. New York: Little Brown and Co.

Back pain: Simple and effective exercises

Introduction: Back pain is a common ailment that affects millions of people worldwide. Whether it's due to poor posture, muscle strain, or underlying conditions, finding relief from back pain is a top priority for many. While medication and rest can provide temporary relief, incorporating physiotherapy exercises into your routine can help strengthen your back muscles, improve flexibility, and alleviate discomfort in the long term. In this blog post, we'll explore the five best exercises recommended by physiotherapists to combat back pain effectively.

1. Cat-Cow Stretch:

• Start on your hands and knees, with your wrists aligned under your shoulders and your knees under your hips.

• Inhale as you arch your back, lifting your chest and tailbone towards the ceiling (Cow Pose).

• Exhale as you round your spine, tucking your chin to your chest and drawing your belly button towards your spine (Cat Pose).

• Repeat this sequence, flowing smoothly between the two poses for 8-10 repetitions. This exercise helps improve spinal flexibility and relieves tension in the back muscles.

2. Bridge Exercise:

• Lie on your back with your knees bent and feet flat on the floor, hip-width apart.

• Engage your core muscles as you lift your hips towards the ceiling, creating a straight line from your shoulders to your knees.

• Hold this position for 5-10 seconds, then slowly lower your hips back down to the starting position.

• Aim for 8-10 repetitions. The bridge exercise strengthens the muscles in your lower back, buttocks, and hamstrings, which can help stabilize the spine and reduce back pain.

3. Bird-Dog Exercise:

• Begin on your hands and knees, with your wrists aligned under your shoulders and your knees under your hips.

• Extend your right arm forward and your left leg back, keeping your spine in a neutral position.

• Hold this position for a few seconds, then return to the starting position and switch sides, extending your left arm forward and your right leg back.

• Repeat this alternating movement for 8-10 repetitions on each side. The bird-dog exercise improves core strength and stability, which are essential for maintaining proper posture and preventing back pain.

4. Child's Pose:

• Start on your hands and knees, then sit back on your heels with your knees slightly apart.

• Lower your chest towards the floor, reaching your arms out in front of you and resting your forehead on the ground.

• Hold this position for 20-30 seconds, focusing on deep breathing and relaxing the muscles in your back.

• Child's pose gently stretches the muscles in the back, hips, and thighs, providing relief from tension and promoting relaxation.

5. Pelvic Tilt Exercise:

• Lie on your back with your knees bent and feet flat on the floor, hip-width apart.

• Engage your abdominal muscles as you flatten your lower back against the floor, tilting your pelvis upwards.

• Hold this position for a few seconds, then release and allow your lower back to arch slightly away from the floor.

• Repeat this movement for 8-10 repetitions. The pelvic tilt exercise helps improve pelvic alignment and strengthen the deep abdominal muscles, which can reduce strain on the lower back.

Conclusion: Incorporating these five physiotherapy exercises into your daily routine can significantly improve back pain symptoms and prevent future discomfort. However, it's essential to consult with a physiotherapist or healthcare professional before starting any new exercise program, especially if you have underlying medical conditions or injuries. Remember to listen to your body and stop any exercise that causes pain or discomfort. With consistency and proper technique, you can strengthen your back muscles, improve flexibility, and enjoy a life free from back pain.

Carpal Bone Fractures: Incidence and the major culprit (Scaphoid)

The carpal bones are a group of eight small bones in your hand. These include

• Scaphoid (Most common 40-70% in literature)

• Lunate (0/5% - 1% rare due to protected position in proximal carpal row)

• Capitate (rare due to its protect position in the middle of the carpus)

• Trapezium (4-5% of fractures)

• Trapezoid (0.5-1%)

• Triquetrum (2nd most common 4-18% in literature)

• Hamate (2% of all fractures (Hook of hamate often a golf club versus ground)

• Pisiform (<1% off all carpal fractures)

Scaphoid Fractures

The most common type of carpal bone fracture is a scaphoid fracture most likely because it is the easiest to identify on a plain x-ray in comparison to other bones. Having said that it can often not seen (known as an occult fracture) then an MRI or CT scan is recommended. Due to the blood supply which passes the bone and has a branch that reverts back the bone is at risk of death (avascular necrosis) or non union (not healing) therefore it is pertinent not to miss this injury.

Treatment in the acute stages is often splinting and review x-ray in 2 weeks is suspicious of a scaphoid fracture. Hand physiotherapist can make a splint to immobilise the wrist and this often includes the thumb. Once confirmed immobilisation can be from 6-12 weeks. With a injury like this it is recommended to work with your physio and sports physician (Sports doctor) to best guide the appropriate treatment pathway if conservative management is not appropriate.

Hulsopple et al (2017) Treatment of acute carpal bone fractures. Current Sports Medicine Reports