Post Fall Syndrome: A Comprehensive Guide

What is Post-Fall Syndrome?

Post-Fall Syndrome manifests itself in at least two ways:

1. The affected person walks less effectively than before; their buttocks point backward, and they no longer press on the front of the foot but rather on the heels.
   
   They are bent forward, and their center of gravity is shifted backward, which is referred to as a retropulsion posture.
   
   They may also struggle to stand upright, even with the assistance of their arms or another person.
2. Sometimes, sitting down is also impossible for the person as they tend to lean backward and become rigid.
   
   They often have little awareness that they are leaning too far back, even if informed about it.

Additionally, the person may develop a fear of walking, getting up, or even sitting on the edge of the bed, out of fear of falling.

This can occur even in the absence of apparent causes, such as fractures or paralysis.

Who has post-fall syndrome?

Post-fall syndrome primarily occurs in individuals aged over 65.

People are at a higher risk if:

• They have had health problems that required them to be bedridden more than usual, following, for example, hospitalization for issues such as cardiac, pulmonary, cancer-related, or orthopedic conditions.
• They have early signs of cognitive disorders (Alzheimer’s, Parkinson’s disease, or a parkinsonian syndrome).
• They have a fear of falling, often as a result of one or multiple falls at home, in the street, or in the hospital.

These falls may have resulted in:

• Hip fractures, whether operated on or not.
• Wrist fractures.
• Trochanter fractures.
• Patella fractures, etc.

It is also sometimes referred to as the Psychomotor Disadaptation Syndrome or Pusher Syndrome.

The latter term is more commonly used to describe the backward-pushing behavior of individuals after a stroke.

In the case of a stroke, the Pusher Syndrome tends to occur when the thalamus, especially its posterior part, is affected (Ticini et al., 2009).

It is called this because hemiplegic individuals often have a tendency to push their body towards the paralyzed side, exacerbating their imbalance.

Studies on post fall syndrome ?

While post-fall syndrome is a syndrome I frequently encounter in practice, there are very few studies in the international scientific literature that address it.

There are significantly fewer studies, for example, compared to the fear of falling in elderly individuals after a fall, which is also a common consequence of a fall.

Moreover, most of the articles are authored by French researchers or occasionally by Europeans.

The first article that is often referenced is that of Pfitzenmeyer et al., 1999.

It explains that this psychomotor regression syndrome has been described in the French medical literature for about 10 years.

Frequency of post-fall syndrome

No studies specifically address the frequency of post-fall syndrome, but several indirectly mention it.

Here is a summary.

Study	Type of Population Studied	Total Number of Participants	Number of Participants with Post-Fall Syndrome	Frequency of Post-Fall Syndrome
Kechaou 2019	Elderly individuals over 65 who experienced at least one fall in the past year, hospitalized or receiving outpatient geriatric care. Country: Tunisia	65	5	12.5%
Alarcon 2006	Individuals hospitalized due to hip fractures. Country: Spain	196	10	5.1%
Miro 2019	Individuals over 65 hospitalized in geriatrics after a fall. Country: Spain	452	236	52.8%

We can observe that the frequency of post-fall syndrome after a fall varies significantly across these three studies.

This variation may be due to the fact that the diagnosis of post-fall syndrome is not very reproducible; there are no clear criteria that two blind examiners can reliably use to diagnose post-fall syndrome.

In any case, this syndrome is relatively common, occurring in at least 5% of elderly individuals after a fall according to these studies.

Consequences of Post-Fall Syndrome

After a fall, elderly individuals often experience a loss of some of their functional abilities.

For example, they may require assistive devices to walk, walk shorter distances, be unable to descend stairs, or have difficulty getting into their bathtub, among other limitations.

Several factors increase the risk of losing functional abilities, including:

1. Age: Individuals over the age of 85 are at a higher risk of losing their functional abilities after a fall.
2. Fracture: Those who sustain a fracture from a fall, most commonly of the hip, shoulder, or wrist, also face an increased risk.
3. Hospitalization: Hospitalization can also elevate the risk of losing functional abilities. However, it’s essential to note that being hospitalized does not necessarily mean individuals will lose their abilities (although it’s possible if they remain bedridden without rehabilitation in an unfamiliar environment).
   
   More likely, it indicates that individuals who are most affected by the fall are hospitalized and subsequently experience a decline in their functional abilities, not solely because of hospitalization.
4. Post-Fall Syndrome: Lastly, post-fall syndrome naturally increases the risk of losing functional abilities and autonomy.

(Miro et al., 2019)

Furthermore, individuals may also develop a fear or anxiety of falling. Physical therapy can be useful in reducing this fear of falling.

Diagnosis of Post-Fall Syndrome

Post-fall syndrome is diagnosed simply through observation of the individual.

Someone experienced in working with seniors can readily identify post-fall syndrome by observing a person seated, standing, or walking with assistive devices for just a few seconds.

There is no need for additional tests to establish the diagnosis.

However, it is possible to have the person assume different positions to assess the severity of the backward-pushing behavior and whether it can be corrected.

Questionnaire-based tests exist to evaluate the fear of falling. One validated test in French that provides a somewhat more reproducible assessment of the severity of post-fall syndrome is the FES-I.

However, in practical terms, this test is rarely employed in the context of post-fall syndrome.

This is because individuals with post-fall syndrome often have limitations that prevent them from performing the actions and activities described in the questionnaire.

Post-Fall Syndrome: Rehabilitation

To date, there are no studies comparing the effectiveness of different types of rehabilitation for addressing post-fall syndrome.

There are also no studies comparing the progress of individuals who receive regular visits from a physical therapist or another rehabilitation specialist with those who do not receive rehabilitation in the presence of post-fall syndrome.

However, in practice, we observe a deterioration in the motor abilities of individuals in the absence of rehabilitation for activities such as sitting, transferring, or walking when supervised by someone experienced with the elderly.

Conversely, a person accompanied several times a week can, in a matter of weeks, regain their previous functional state and regain the ability to perform transfers or walking that they could not manage since their post-fall syndrome.

Rehabilitation involves relearning functional movements that have become difficult to execute. To achieve this, physical therapists guide individuals through exercises and postures to reacquaint them with not being in a backward-pushing position and help them shift their center of gravity forward.

It is essential to avoid allowing the elderly individual to develop a habit of being pulled up by the hands or shoulders, as this exacerbates the backward-pushing behavior. Encouraging them to push on their hands is preferred.

Physical therapists encourage individuals with post-fall syndrome to do as much as possible on their own. Verbal guidance and minimal physical assistance are provided to help them relearn various daily activities.

The choice of an appropriate walking aid is determined in consultation with physical therapists.

This often involves a two-wheeled walker initially (see this article on choosing a walker for Parkinson’s disease; these recommendations also apply to individuals with post-fall syndrome, as they share common characteristics with those with Parkinson’s disease).

Some tips

Among the techniques employed by physical therapists are:

1. Instructing the person to reach out with their head, then their chest and pelvis, toward the physiotherapist’s hand or body placed in front of them.
2. Placing a small board under the front of the elderly person’s feet while in a standing position to help them regain the sensation of shifting their center of gravity forward to prevent falling.
3. Purposefully utilizing lightweight assistive devices that cannot be pulled, such as a lightweight walker (physiotherapists can prescribe these walking aids for reimbursement).
4. Encouraging them to push on armrests of a seat rather than pull on a rail or assistive device when getting up.
5. Avoiding the use of transfer bars that promote pulling.

The main challenge is to find the postures and exercises that help restore confidence in the elderly individual and engage their motor abilities to an appropriate extent, without putting them at excessive risk but still taking them out of their comfort zone.

There are no formal contraindications for rehabilitating a post-fall syndrome, even in the presence of other conditions such as heart failure.

What studies say?

Only one study has described the progress of several individuals who experienced a post-fall syndrome and underwent rehabilitation sessions. This study involved 13 women over 70 years old who were hospitalized following a fall and a post-fall syndrome.

They did not have major cognitive impairments, fractures resulting from the fall, or acute illnesses or discomfort during the fall.

They received 45 minutes of daily rehabilitation during their hospitalization, focusing on eliminating the retropulsion posture and regaining functional abilities such as transfers and walking.

In a later stage, rehabilitation focused on improving balance. The average length of hospitalization was 20 days. This study shows that:

• Individuals improved their scores on tests assessing their ability to rise from a chair and walk as quickly as possible over 6 meters (Timed Get-Up and Get-Up and Go tests).
• Individuals improved their scores on a test evaluating their functional and postural abilities.
• 6 out of 13 individuals were able to independently rise from the ground after rehabilitation.

(Pfitzenmeyer et al. 2001)

Post-Fall Syndrome: Multidisciplinary Management

Multidisciplinary collaboration is essential for the successful rehabilitation of post-fall syndrome as quickly as possible.

It is crucial that all caregivers involved with the individual (family caregivers, nursing assistants, home health aides, doctors, occupational therapists, physiotherapists, etc.) adopt a unified approach towards post-fall syndrome: reassuring the affected person while encouraging their active participation in all daily activities without exacerbating their retropulsion posture.

This is particularly important during transfers and nursing care.

Physiotherapists can educate families and healthcare professionals on how to manage a person with post-fall syndrome to prevent worsening their psychomotor maladaptation.

Prevention of Post-Fall Syndrome

The advice given for managing post-fall syndrome is, in fact, applicable to assisting anyone who needs help with mobility, whether they are children with cerebral palsy or a genetic disorder, adults recovering from accidents with orthopedic or neurological consequences, or seniors with or without a history of falls.

Emphasizing techniques such as pushing rather than pulling, and encouraging individuals to do as much as they can for themselves, can help prevent the development of retropulsion posture in geriatrics, or at least delay its onset or severity.

Physiotherapy sessions can also help reduce the risk of falls in people over 65 years of age. Individuals with Parkinson’s disease are potentially at higher risk of developing post-fall syndrome.

What Is the Recovery Time After Post-Fall Syndrome?

A Franco-Swiss team tracked the progress of individuals aged 70 and older who had experienced a fall. They compared the outcomes of individuals diagnosed with post-fall syndrome versus those without post-fall syndrome (Meyer 2021).

Here are their key findings:

Among patients with post-fall syndrome,

• 52.9% could still perform a transfer one year later (compared to 80.7% of those without post-fall syndrome). For example, getting out of bed to a chair or transitioning from a seated to standing position without assistance.
• 64.7% could still walk (compared to 85.2% for patients without post-fall syndrome).

Here are the characteristics more commonly found in individuals who experienced post-fall syndrome:

• Older age.
• Pre-existing walking difficulties before the fall.
• Use of mobility aids before the fall.
• Lack of unsupervised outdoor walks in the week preceding the fall.
• Visual impairment preventing close-up reading.
• Ankle dorsiflexion stiffness.
• Reduced grip strength.
• Fear of falling.

Clinical Cases (Examples) of Post-Fall Syndromes

Here are some examples of post-fall syndromes in patients I have treated in physiotherapy over the past few years.

Some details have been modified to respect the anonymity of the individuals but do not significantly alter the clinical cases.

Patient: Mrs. H

Background and Previous Independence:

Mrs. H is 85 years old and has undergone several knee and hip prosthetic surgeries over the past 5 years due to coxarthrosis and gonarthrosis. Until she developed cancer a few months ago, she was completely independent. She walked without assistive devices and had never fallen. She had no cognitive impairments.

Causes and Onset of Post-Fall Syndrome:

She remained bedridden and in a wheelchair for approximately 2 months due to her cancer, chemotherapy, and surgery. She then went to a rehabilitation center.

At that point, she had a moderate post-fall syndrome that prevented her from standing up. She performed her transfers using a mechanical lift.

She received physiotherapy sessions approximately 3 times a week. On some days, she managed to stand up using parallel bars and take a few steps, but the post-fall syndrome persisted.

She needed traction (pulling on her arms from a fixed structure like parallel bars or a walker held by a caregiver) to remain upright.

Towards the end of her stay in the rehabilitation center, transfers were done using a walker with the presence of a caregiver. Unfortunately, Mrs. H fell three times during this period.

When she returned home, her post-fall syndrome had worsened due to her falls. Sitting at the edge of the bed was impossible without significant assistance from a caregiver, and it was done in total retropulsion.

Transfers with a walker and standing were no longer possible due to the post-fall syndrome, even though Mrs. H was very eager to regain her ability to walk.

Rehabilitation of Post-Fall Syndrome:

The physiotherapy sessions initially aimed to help Mrs. H regain an independent sitting position to facilitate transfers and dressing.

To achieve this, a gradual withdrawal of assistance for sitting at the edge of the bed was implemented. Initially, the physiotherapist supported Mrs. H’s back with both hands. Gradually, the push exerted to keep her seated was reduced.

The instruction for Mrs. H was to lean her chest as far forward as possible. Her two hands had to be placed on the bed without trying to pull the sheets or the mattress.

After approximately 3 sessions of about 20 minutes each of this exercise, Mrs. H had regained the ability to sit independently without using her arms, other than placing them on the bed.

However, the retropulsion posture occasionally returned during extended periods of bed rest or significant fatigue.

Once the sitting position was achieved, standing was considered. Mrs. H was initially stood up using a walker on which she was allowed to pull to remain upright.

The goal was to regain the ability to stand upright, even if it meant eliciting retropulsion. Once Mrs. H had regained sufficient leg strength, endurance, and stability to stand in these conditions, the withdrawal from standing retropulsion was initiated.

For this, the physiotherapist no longer kept the walker firmly on the ground but gradually held it less and less. The instruction was for Mrs. H not to pull on the walker but simply place her hands on it. She was encouraged to move her chest forward again.

After approximately 5 sessions of about 10 minutes each in a standing position (while continuing seated exercises), independent standing with the walker without retropulsion was possible and maintained for 2 minutes. Walking a few steps then became possible.

Unfortunately, joint pain in the knees and hips halted the walking rehabilitation. Only standing for transfers was maintained over time.