J9k00158.jpg (5851 bytes)The participants who enter a pulmonary rehabilitation program come with a variety of issues related to their breathing and its medical management. They also come with many other physical conditions that can have an impact on their ability to function within their homes and communities as well as within the rehab program. Positive outcomes for the program and its participants depend on effective identification of the functional limitations that affect participants’ safety, as well as the risk management issues of the facility.

Falls are one of the most prevalent sources of injury occurring among the elderly, both at home and within the hospital setting. Falls occur most often in the performance of everyday activities such as transferring on and off chairs, beds, or toilets; getting in and out of bathtubs or showers; reaching or bending to retrieve or to place objects; and walking about or going up and down stairs.1

Fall risks are related to a number of conditions, all of which may exist in the aging and often debilitated people presenting to a pulmonary rehabilitation program. Issues contributing to fall risk include diminished sensory input, reduced strength and balance, and impaired cognitive status.

In the rehab setting, participants are placed in an unfamiliar environment filled with exercise equipment of varying heights, unfamiliar shapes, and textures. Equipment may have unstable, moving components, such as sliding or swiveling seats, pedals that rotate or shift, and irregular bases with “feet” or wheels that can stick out several inches from the main body of the object. Add to those problems an increase in visual and auditory stimulation due to the gym atmosphere.

In many cases, exercisers must lower themselves onto equipment such as rowers or recumbent cycles, must straddle the bars of cycle ergometers, or step up onto the pedals of a stair simulator or the belt area of a treadmill. The treadmills used in rehab facilities often require participants to step onto a moving belt. All of these activities, and countless more, can present major risks of falls and injuries to the very people whose health we are trying to improve. By recognizing activities involving high risk, and evaluating participants for fall risk factors, a rehabilitation facility can take measures to provide a safer environment for the older exerciser.

Factors that can precipitate a fall can be divided into the extrinsic and intrinsic. Extrinsic factors are hazardous environmental conditions, while intrinsic factors are the age-related, physiologic changes, pathologic conditions, and even adverse medication effects occurring in the participant. Many fall risk factors can be identified and controlled, if not eliminated all together.1

Under the category of age-related changes are such issues as decreased vision and hearing; changes in balance; decreases in strength, flexibility, and reaction time; and changes in gait. Pathologic conditions may include frailty, osteoporosis, osteoarthritis, rheumatoid arthritis, hypotension, neurologic disorders, peripheral neuropathy, anxiety and depression (which can contribute to distractability or lack of attentiveness), and early dementia, as well as macular degeneration and cataracts. Some medications can contribute to sedation or postural hypotension.

The definition of frail older adult includes extreme old age, having some type of disability, or the presence of multiple chronic diseases or geriatric syndromes. While exercise can increase strength, flexibility, coordination, and balance, which can result in decreased risk of falling, the initiation of the exercise program may present greater risks.2

Patients with osteoarthritis and rheumatoid arthritis present additional risks. They may be less flexible and weaker because pain limits their ability to exercise; they may also be more guarded in their movements as a result of their pain. Prolonged inactivity results in disuse atrophy.

Osteoporosis is a common condition among pulmonary rehab participants since many of them have taken multiple and prolonged courses of corticosteroids, are female, and have become increasingly inactive. A second consequence of frequent steroid use is thinner, more fragile skin. Even without orthopedic injury, skin tears and excessive bruising can be quite significant with only minor impact or abrasion. Muscle atrophy of the proximal joints (hips and shoulders) is also a frequent complication of prolonged steroid use.

With regard to vision in the elderly, many age-related changes take place, and these can directly affect how the person perceives his surroundings. Visual acuity is the ability to distinguish subtle differences in shape; contrast sensitivity involves the ability to differentiate spatial detail and object contrast. Color sensitivity also decreases, particularly affecting cool colors such as blues, greens, and violets. This is more pronounced in decreased light. A decline in depth perception, the ability to judge distances and space relationships, and decline in light sensitivity, the ability to adjust to dim or bright light, as well as an increased sensitivity to glare, can all contribute to difficulty in maneuvering in a strange environment.1

Macular degeneration results in the loss of the center of the visual field. While able to distinguish light, color, and movement, visual acuity is very limited, and patients must rely on their peripheral vision for navigation and function. Referral to a low vision clinic may be helpful to improve community and home function.

Cataracts are the result of clouding of the lens of the eye. Common complaints include difficulty reading printed materials, increased glare sensitivity, and decreased visual acuity. The consequences of decreased vision can include tripping over the feet or wheels of equipment or misjudging the distance between two objects. Participants with both of these types of vision problems will need assistance not only in navigating the rehab space, but also with adjusting settings on equipment. Vision is also a key factor in maintaining balance.

Balance is defined as the ability to position the body’s center of gravity over its base of support. When standing, that base is the soles of the feet; when sitting, it is the interface with the seat. Balance is affected by several components. Proprioception is the input that the body’s sensors provide on the immediate environment. It allows the body to orient itself to standing or motion, including the stability beneath the base of support, and the body’s parts as they relate to each other. Joint position sense, pressure sensors, and vibration sensors all contribute to proprioception. This is diminished in diabetic neuropathies, some circulatory disorders, and many other diseases. Because proprioception declines with age, older people tend to rely more heavily on vision to maintain balance.1

Vestibular input is the information relayed from the leveling mechanisms of the inner ear. This may be affected in patients with hearing problems, strokes, head injuries, and other neurologic diseases. Participants with a vestibular deficit may complain of feeling woozy or light-headed. It is important to differentiate hypotensive light-headedness from a vestibular problem.

Once a person receives all of this input, he must react to it. Derangement in the compensatory mechanisms that allow the body to correct itself may occur in some neurologic and muscular disorders. During an intake assessment, it often becomes necessary to decipher from a person’s verbal history and identify factors that could increase risk. Comments often heard include: “I’ve always had weak knees (ankles, etc)”; “They thought I had a stroke, but then said I didn’t”; or “They never figured out why I passed out.”

Impaired gait is a frequent problem in the older person. The flexibility of the foot and leg components, muscle strength, step length, walking base length, and speed are all factors that affect the stability of walking. A patient’s gait can deteriorate with fatigue, even in the span of a 6-minute walk. Patients will often deny the need for an assistive device; however, secondary to their dyspnea, they may not be walking enough to become aware of the deterioration. Also, it is not uncommon for oxygen consumption to be positively affected by the use of an appropriate assistive device.

Cognition can be impaired in many ways. Impulsivity, failure to perceive risks, difficulty in learning new tasks, and impaired judgement of one’s ability to safely perform a task are all factors to assess. Conditions that affect these factors include chronic hypoxemia,3-5 multiple transient ischemic attacks, cerebral vascular accidents, early dementia, and other central nervous system disorders.

To evaluate fall risk in a potential rehab participant, all of the above should be assessed. The guidelines for pulmonary rehabilitation do recommend performing fall risk assessment, and suggest the Tinetti scoring system.6 This system is designed to quickly assess static and dynamic balance seated, standing, and walking. However, as with all assessment tools, its accuracy is dependent on familiarity with the tool and frequency of use.

Accidents attributable to environmental hazards constitute 25% to 45% of all falls. However, most falls can really be attributed to the interaction between environmental factors and susceptible individuals.7 Extrinsic factors include the flooring, arrangement of equipment, assuring absence of clutter, and proper footwear for exercise participants.

Flooring in the rehab area can be either smooth (tile or linoleum) or carpeted. Since reduced visual accommodation to glare can be a problem in older people, highly polished or reflective surfaces should be avoided. Also, if liquid oxygen stroller units are used, these units do occasionally have some condensation and dripping, and even tiny puddles of water can be a slipping hazard on a smooth floor.

In most cases, carpeting designed for high-traffic areas is fine, as long as the pile is not too deep, and the padding does not allow too much give. Carpeting with too much give will affect the sense of stability of the foot and ankle. Carpeting may also eliminate slipping risks and mistakes in identifying a floor as slippery because of reflection or glare.

Carpeting should not have large patterns or designs. These contrasts can be misinterpreted as irregularities or obstructions on the floor by someone with impaired vision. The color should not be too dark, since a lot of exercise equipment is dark in color and the extended feet or supports may not contrast well enough with a dark surface. Using yellow or white tape or paint on the edges of dark equipment may also provide improved visibility.

Spaces between equipment should be unobstructed and wide enough to allow comfortable, unencumbered passage, without need for excessive agility, and should allow for use of assistive devices. Loose equipment, such as hand weights, cuff weights, and other small objects, should be stored on racks, against walls, or in low traffic corners to reduce the risk of tripping.

Proper footwear should be encouraged among exercisers. Shoes should be properly fitted. Shoes that are too small can compress the foot, causing pain and, hence, altered gait. Loose footwear may result in a shuffling gait, which can lead to tripping. Patients with leg, foot, or ankle edema may have an especially difficult time with proper fit.1

Supportive walking or athletic shoes are ideal. However, occasionally women may arrive in sandals, dress shoes with smooth soles and higher heels, wedgies, and even clogs or mules. Shoes with open toes and no heel coverage should be discouraged due to the risk of toe injuries and the risk of the shoe coming off the foot. It should be noted that some older women who have worn high heels a long time may have shortened heel cords and they may not be able to tolerate flat or athletic shoes. Some older men may wear their dress shoes to the exercise sessions. The stiffer, smoother leather soles may also present a slipping hazard. Information on appropriate exercise attire and footwear can be included in a letter prior to the start of the program.

Participants should be instructed in proper use of all equipment. Be aware of the environment in which instruction is given. Most participants will need several exposures to the equipment, and should be instructed one-on-one. Often, participation in a pulmonary rehabilitation class is the first experience many of these people have with exercise equipment. Some have never walked on a treadmill at all, or, if they have, it may have been for a stress test, which is not the most accurate representation of this equipment. If possible, when purchasing a new treadmill, look for a model with a belt that remains motionless for the first few seconds when the unit is started, then starts to move very gradually. This avoids having a person step onto a moving belt. Also, when working with very low-level patients, having a treadmill that has a minimum speed of 0.5 mph may be preferable to one that starts at 0.9 mph.

Many treadmills come equipped with an emergency shutoff feature that uses a clip-on cord with hook-and-loop attachment. The clip is attached to the walker, and should the user move backward or fall, the hook-and-loop connection is broken and the treadmill stops. Another safety feature that is well worth the investment is an emergency power switch located near the room’s central point, such as the therapist’s charting station or telemetry monitors. Such a power switch can be wired to the wall outlet powering the treadmill, and, in the event of a fall, the power can be cut. The abrasions from a treadmill’s belt can be quite painful, and may be reduced or avoided by these features.

Loss of balance is a risk whenever a person tries to stand on one foot to step onto or over something. Whenever possible, patients should be discouraged from stepping over or straddling equipment, such as low bikes or rowers, in favor of sitting down “sidesaddle” and transferring the leg while seated. Also, apprise exercisers of the moving parts of all equipment, such as the arm handles on a cycle, that can shift if leaned on. Safety reminders should be given in the initial introduction to equipment and should be repeated frequently. As participants become more familiar with equipment, they may relax their vigilance.

For people who are particularly weak or debilitated, as well as those who are obese, caution should be exercised in using exercise cycles with saddle-type seats. It requires a degree of stability to assume and maintain a proper seat on a narrow saddle. Cycle seats are often angled so that a person can slide forward and slip off. A weaker individual may not be able to catch himself and prevent a fall. A recumbent cycle with a “tractor” seat may be better suited to these individuals. Obese patients may not be able to use the recumbent cycle due to their abdomens. Another alternative is a certain type of cycling device, which can be attached to a regular chair. This chair can be higher than the recumbent cycle, thus making it easier to sit and rise. This device also works well with patients with hip range of motion limitations such as joint replacements.

When beginning an exercise program for patients who are deemed to be at high risk for falls due to leg weakness, exercises with ankle weights may lay a foundation for strengthening the thigh and hip muscles that affect gait and balance compensation. If a physical therapist is not a standard component of the rehab program, a consultation is indicated for the most appropriate exercises.

Precautions to institute in the event a person meets the criteria for high fall risk should include guarded transfers, assistive devices, use of handrails for support during static standing activity, and performing activities seated whenever possible. The patient’s record should reflect documentation that all members of the treatment team are aware of the fall risk. The identification should be reported to the physician as well, since many times a physician may never see the patient walk. Recommendations for physical therapy assessment or neurologic workup may be included in your report.

Preparation for all team members in the pulmonary rehabilitation program should include familiarity with the institutional procedures for any emergency. Some institutions have separate systems for cardiopulmonary emergencies and other types of incidents such as falls. The correct telephone access number should be posted, or, if available, a telephone key may be preprogrammed. If exercise sessions are managed by only one person, a backup person should be designated and readily available in the event of an occurrence.


In summary, fall risk management is an ongoing process throughout a patient’s entire length of stay. Thorough physical evaluation, combined with vigilant awareness of hazards and a comprehensive fall-prevention system, can ensure the participants in a pulmonary rehabilitation program the most positive of outcomes, and not more problems than they brought with them.

Carlie Ream, MA, RRT, CPFT, is coordinator of pulmonary rehabilitation at St Agnes HealthCare in Baltimore; and Cathy Kelsh, PT, is a home care physical therapist.


1. Tideiksaar R. Falling in Old Age: Its Prevention and Management. 62nd ed. New York City: Springer Publishing Co Inc; 1996.

2. American College of Sports Medicine. ACSM’s exercise management for persons with chronic diseases and disabilities/ American College of Sports Medicine. Champaign, Ill: Human Kinetics; 1997.

3. Grant I, Heaton RK, McSweeny AJ, et al. Neuropsychologic findings in hypoxemic chronic obstructive pulmonary disease. Arch Intern Med. 1982;142:1470-1476.

4. Gibson GE, Pulsinelli W, Blass JP, Duffy TE. Brain dysfunction in mild to moderate hypoxemia. Am J Med. 1981;70:1247-1253.

5. Grant I, Prigatano GP, Heaton RK, et al. Progressive neuropsychologic impairment and hypoxemia. Arch Gen Psy. 1987;44:999-1006.

6. American Association of Cardiovascular and Pulmonary Rehabilitation. Guidelines for pulmonary rehabilitation programs/ American Association of Cardiovascular and Pulmonary Rehabilitation. 2nd ed. Champaign, Ill: Human Kinetics; 1998.

7. Kenny R. Syncope in the Older Patient: Causes, Investigations and Consequences of Syncope and Falls. London: Chapman & Hall; 1996:286-287.