2021 AGM - Falling With HSP

The 2021 AGM presentations followed the path established in 2020, with talks scheduled after the AGM on separate days. Our second presentation was Coralie Seary who is a physio from the National Hospital for Neurology and Neurosurgery in London. She talked about falling with HSP. Her work is in the clinic rather than research and she specialises in helping people with walking difficulties, most usually with FES or orthotics.

You can see the video of the presentation here: https://www.youtube.com/watch?v=f68yaDzYtvQ

Most of the information about people who fall is based on the elderly. One in three people who are over 65 have about 1 fall per year, increasing to one in two over 80. Those with neurological problems are twice as likely to fall as those without.

If you have a serious fall it can lead to a serious spiral with people fearing falling, people being less active, leading to decreases in strength or balance, leading to another fall, and so on.

There is a range of falling, with the most extreme being falling to the ground, but there are also near misses where you can prevent yourself from falling, and trips and stumbles. 

Falling is normal! Some falls can be considered acceptable whereas others are not acceptable. Acceptable falls are ones where you dont injure yourself or have a head impact. They might also occur where you are in a challenging balance situation - perhaps uneven/slippery ground or during sport/exercise. Unacceptable falls are where you do have injury/head impact, if it is a normal everyday activity or if you are in a vulnerable population. Coralie noted that having HSP is more likely to put you in a vulnerable population.

Risk Factors for Falling - Intrinsic

There are a number of generic risk factors which increase your risk of falling. If any of these apply then with some management they may reduce your risk of falling.

• Being older (older than 65)
• Having a walking impairment
• Having other chronic conditions (perhaps arthritis)
• Reduced muscle strength
• Impaired balance
• Fear of falling can increase your risk of falling again
• Dizziness (perhaps from postural hypotension)
• Inner ear/vestibular problems
• Vision (make sure your glasses prescription is up to date)
• Foot problems (painful corns, toenails, appropriate footwear)
• Poly-pharmacy - taking multiple medications
• Alcohol

Pairing one or more of these with HSP can increase your risk of falls further. Some of these can be managed to improve risk.

Risk Factors for Falling - Extrinsic

There are a number of other risk factors which increase your risk of falling.

• Light levels - either very dark or bright glare
• Obstacles around the house - wires, rugs, piles of books/toys, etc.
• Surfaces that you walk on - can choose footwear/aids to help in some circumstances
• Footwear - some types of shoes can help walking. Make sure shoe laces are tied
• Clothing - long clothing can get in the way of walking
• Ergonomics - minimise the number of turns you have to do to complete tasks, for example making a cup of tea in the kitchen 
• Use of inappropriate walking aids - check your aids are still appropriate, and clear out old ones.

Similarly, these can be considered so that you minimise the risk of falling.

Risk Factors for Falling - HSP Specific Factors

There are a number of other HSP specific risk factors which can increase your risk of falling.

• Gait patterns - inversion of joints, knees
• Weakness - hip areas, of perhaps its the timing of movement rather than weakness
• Stiffness - can cause imbalance
• Alignment of bones - can change centre of balance
• Sensory changes - e.g. change in information from skin to brain
• Fatigue - plan your day and energy use according to your expected fatigue levels
• Bladder problems - urgency can increase risk of falls, including at night.
• Reduced capacity for dual tasking

Aids to reduce risk of falling

There are aids which you can use to reduce risk of falling (and improve mobility), but it is recognised that often people have difficulties accepting the need for these devices. The best approach is to get used to using aids before having a fall, so some acceptance is needed.

Orthotics are external splits or aids to help pick your feet up and/or stabilise your gait. They can improve stability and/or the swing of the leg. 

Off the shelf orthotics are more flexible and can be a good introduction to using them. Custom made ones are usually more rigid and give you more control of the ankle/foot.

Insoles (or FFO, functional foot orthoses) can help control pronation (where feet roll in) or supination (where the foot rolls outwards).

Choosing your footwear can help a lot. The important factors are the shape of the sole, with a reasonable wedge to raise the heel and a toe spring at the front to help roll forwards on your foot. Some people find high boots are useful, and there are options for adapting existing shoes.

Neoprene or fabric ankle/knee supports/splits can give some support. Some look sporty others attach to your shoes. Carbon AFOs can give you some energy back when walking. The last type is a custom-made plastic AFO which gives the most support. The AFO can help re-align the leg and hip to improve gait. There are advantages and disadvantages to each type depending on what you need to do. There is NOT a one-size fits all approach for these with HSP.

An FES system stimulates the muscles when you move. They do not give you support when you stand still. They can help you walk further. Evidence suggests that using FES can improve peoples confidence walking rather than their walking speed or funciton.

Other aids to minimise risk of falls that you could use are walking poles, mobility scooters, wheelchairs, grab rails, stools (for sitting on), rollators/trolleys, adaptions to bath/shower. You may need different aids in different situations - indoors/outdoors, at home/away, etc. If you have these around your house and do not use them any more they can be an obstacle - get rid of them!

What else can you do?

• Exercise can help. Tai Chi is beneficial in older people in reducing risk of falling, and the benefit could be extrapolated for use in HSP or other neurological conditions 
• Strength and balance training is useful.
• Exercise should be high dose for benefits (least 50 hours over 6 months). Do something you enjoy!
• Stretches - maintain mobility, especially in calves
• Look at diet to maintain bone health - take calcium and/or vitamin D if diet is suboptimal or your are not doing weight bearing activities

How to fall

Plan how to fall. Consider the risk factors above. If you fall in one place then plan for a softer landing. You should relax and protect your head, and fall on your fleshy bits of your body. Falling on your bottom may be better than falling on your wrists. 

If you're able to, roll into the fall. You can find out better ways of falling - look up approaches that people with cerebral palsy follow - they can fall often.

Keep your mobile or an alarm handy so that you can get help, and if you live by yourself you may need a key safe so that people can get in to help you. It may be worth keeping blankets/pillows so that you are unable to get up you can keep yourself warm overnight.

To get up off the floor you should stay calm and assess the situation. It is worth practicing getting up so you've done it a few times. You can discuss falling and getting up techniques with your physio.