Post-fall syndrome

Post-fall syndrome (also called ptophobia, or the post-fall anxiety syndrome) was described by Murphy and Isaacs in 1982 as a disabling psychomotor state occurring after a fall in an older person, characterised by fear of falling, loss of postural confidence and a stereotyped abnormal posture and gait, in the absence of any neurological lesion sufficient to explain it.

It is a geriatric emergency of function: the disability is out of all proportion to the physical injury sustained, and it can convert an independent older person into a bed- or chair-bound one within days.

It typically follows a fall associated with a long lie, an injurious fall, or a fall witnessed by an anxious family.

Psychological component: intense fear of falling, anxiety, loss of self-confidence, refusal to walk, and sometimes frank depression.

Postural component (retropulsion): the trunk is thrown backwards when standing or transferring, with the centre of gravity displaced behind the base of support.

Gait component: hesitancy in initiating gait, short shuffling steps with the feet barely leaving the floor (“marche à petits pas”), a wide base, absent arm swing, and clutching or grasping at furniture and at the examiner.

Failure of protective reactions: the person does not put the arms out to save themselves and does not step to correct a perturbation.

It is sometimes described in three stages: acute (immediate fear and refusal to stand), sub-acute (retropulsion and clutching gait) and chronic (established immobility and dependency).

Kane records that even when the fall does not cause serious injury, substantial disability may result from fear of falling, loss of self-confidence, and restricted ambulation — either self-imposed or imposed by caregivers.

Impaired mobility leads to the full spectrum of complications of immobility: pressure ulcers, muscular deconditioning and atrophy, contractures, bone loss, cardiovascular deconditioning, orthostatic hypotension, venous thrombosis and embolism, reduced ventilation with atelectasis and aspiration pneumonia, constipation and faecal impaction, urinary retention and infection, negative nitrogen balance, and psychologically sensory deprivation, delirium and depression.

Reduced activity causes further loss of musculoskeletal and neurological reserve, so the risk of the next fall increases — a vicious cycle.

Fear of falling reduces the cognitive resources available for gait and balance control (impaired dual-tasking), which itself worsens gait.

End results are loss of independence, caregiver burden, increased risk of institutionalisation and increased risk of death.

Recognise it clinically: a patient who will not stand or walk after a fall despite adequate analgesia and no fracture has post-fall syndrome until proved otherwise.

Exclude organic causes of the refusal — occult hip or pelvic fracture, subdural haematoma (neurological signs days to weeks after the fall), acute stroke, delirium, pain, and drug effect.

Quantify fear of falling with a scale: Falls Efficacy Scale-International (FES-I) or the short FES-I, or the Activities-specific Balance Confidence (ABC) scale. Quantify gait and balance with the Tinetti POMA and TUG.

Get the patient up early. The single most important step is early, supervised, graded mobilisation — prolonged bed rest converts a reversible syndrome into permanent immobility.

Physiotherapy: progressive balance and functional training, lower limb strengthening, transfer and gait retraining, and specific practice of backward disequilibrium correction and protective stepping reactions.

Teach the patient how to get up from the floor (backward chaining) — this directly reduces the fear and prevents a future long lie.

Cognitive-behavioural approaches and psychological support, treatment of coexisting depression, and reassurance and education of the family, who are often the source of the restriction (“don’t walk, you will fall again”).

Occupational therapy for home hazard modification, grab bars and correct-height furniture; appropriate walking aid with training; well-fitted footwear.

Provide a personal alarm or pendant and arrange a check-in system for the elder living alone. Withdraw fall-risk-increasing drugs and treat the underlying cause of the index fall.