Older Adults’ Perceptions Regarding the Role of Physical Therapists in Falls Prevention: A Qualitative Investigation

Abstract

Background and Purpose:

Falls are a leading cause of injury, morbidity, and mortality among older adults. Physical therapists are underutilized for falls prevention despite strong evidence and recommendations regarding the effectiveness. The purpose of this study was to explore older adults’ awareness of and perceptions regarding the role of physical therapists for falls prevention. A secondary purpose of the study was to identify barriers to utilization of preventive rehabilitation services.

Methods:

A qualitative descriptive phenomenological approach was used. Participant demographics and falls history was obtained with a standard questionnaire. Four focus groups were conducted with 27 community-dwelling older adults (average age = 78 years). Focus groups were recorded, transcribed, and coded using thematic analysis.

Results:

Surveys indicated 37% of participants experienced a fall in the last year and 26% reported suffering an injury. Four main themes and five subthemes about older adults’ perceptions of physical therapy providers emerged: (1) Awareness of Falls Prevention (subthemes: I Can or Have Taken Action to Prevent Falls, I Don’t Think About It, I Am More Careful); (2) Learning How to Fall and Being Able to Get Up from the Floor; (3) Limited Knowledge Regarding the Role of Physical Therapists for Falls Prevention, and 4) A Physical Therapist Should be seen for a Specific Problem, or After a Fall (subthemes: Perceived Need and Costs, Access Requires a Doctor’s Prescription).

Conclusion:

Older adults lack awareness about the role of physical therapists for falls prevention, believing they should only seek treatment from a physical therapist to address a specific problem, or after a fall. The profession should consider addressing misconceptions and underutilization by educating the public that physical therapists can and do play an important role in the prevention of falls. Being explicit about the prevention of falls throughout an older adults’ episode of care may further help reinforce the role of physical therapists for falls prevention and improve dissemination of this knowledge.

INTRODUCTION

Falls are the leading cause of injury and related mortality among older adults.^1,2 The risk factors for falls are multifactorial, including but not limited to physical issues such as impaired balance, strength, problems with gait, pain, and mobility.³ Healthy People 2030 promotes objectives to develop strategies to reduce falls, their consequences, and fall-related deaths.⁴ Many falls are preventable with evidence-based falls prevention, which includes screening all older adults for falls risk annually and, conducting a multifactorial risk assessment and providing targeted interventions for older adults at risk.⁵ The American Physical Therapy Association-Geriatrics’ (APTA) clinical guidance statement asserts that physical therapists (PTs) should screen all older adults annually for fall risk and provide assessments and interventions within their scope of practice for older adults at risk.⁶ Strength and balance exercise interventions supervised by a PT for older adults at risk of falls are promoted by the Centers for Disease Control and Prevention (CDC)⁷ and the United States Preventive Services Task Force (USPSTF).⁸ A Cochrane review conducted by Sherrington and colleagues found that exercise targeting balance and function reduces the number of older adults that experience a fall by 15% and the number of falls by 23%.³

Despite the evidence and recommendations, PTs are underutilized for falls prevention. Data from the National Health and Aging Trends Study (NHATS) 2015 wave indicates only 13% of older adults at moderate risk for falls and 35% at high risk for falls saw a PT for to address falls, while only 14% of older adults who undergo any type of rehabilitation annually reported falls as the primary reason for attending.⁹ The reason for low rates of rehabilitation utilization for falls prevention are unclear. One potential reason may be the lack of awareness.¹⁰ Understanding older adults’ awareness and perception of the role of PTs for falls prevention may be an important first step to decreasing falls among older adults by increasing utilization rates for those at risk. Therefore, the purpose of this study was to determine older adults’ awareness of and perspectives regarding the role of PTs for falls prevention, and determine potential barriers and facilitators to utilization of preventive rehabilitation services.

METHODS

Ethical Considerations

The Institutional Review Board approved this study. All participants provided verbal informed consent.

Design

A descriptive phenomenological approach was used.¹¹ This type of methodology is useful for gaining insight into experiences through the lens of older adults who have received treatment by a PT, have family or friends who have received treatment from a PT, have participated in fall prevention activities, or who have had previous falls. This method seeks to describe patient perceptions of the role of PTs in fall prevention. Participants also completed a standard questionnaire to gather demographics, brief medical, and falls history prior to participant in an in-depth, semi-structured focus group.

Participant Sampling

Individuals who had participated in a prior, unrelated research study and indicated they were interested in being considered for other studies were contacted. Snowball sampling¹² was used, that is, interested participants were asked if they knew of other older adults who have had experience with the phenomenon under study. Researchers provided their direct contact information to the older adults to share with others who were interested.

Data Collection

Krueger’s guide to designing and conducting focus group interviews was followed.¹³ This guide provides systematic details on how to conduct focus group research; such as planning, developing and pilot testing interview guides, conducting and moderating focus groups, and analyzing and reporting the data. The study team developed and iteratively refined a semi-structured interview guide based on constructs from the Health Belief Model (HBM, Table 1); perceived susceptibility, perceived severity, perceived benefits, perceived barriers, cues to action (stimulus needed to trigger a decision to take action), and self-efficacy.¹⁴ The constructs help explain an individual’s perceptions of the threat of a health problem, the benefits of addressing the threat, and factors that influence the decision to practice a health-promoting behavior. Prior to this study, three pilot interviews were conducted to test the interview guide and support its content validity. The pilot data substantiated the quality of the interview guide. The pilot interview data were not included in the study. The interview guide was used to facilitate focus groups’ in-depth interviews with older adults about their perceptions of falls, prevention, and the role of PTs in falls prevention. See table 1/figure 1

Table I.

Semi-structured interview Questions

1.	Tell me what you know about older people having a fall or multiple falls. What do you think most older adults know about their risk of falling?
2.	Tell me about how falls have or have not personally affected you?
3.	Tell me about information, if any, you have gotten about falls and preventing them?
4.	Tell me about how habits may help or hurt you or others to prevent falls
5.	Tell me about how you feel about your control or lack of control over preventing a fall?
6.	Explain to me what older adults think about engaging in falls prevention behaviors. What would help an older adult to engage in falls prevention behaviors? What is the best way to get information to older adults about falls prevention?
7.	What role, if any, do you feel physical therapy plays in preventing falls?
8.	How easy or difficult do you believe physical therapy is?
9.	What might help someone with to go to physical therapy?
10.	What might keep someone from going to physical therapy?
11.	Is there anything you would like to tell me that we did not talk about today?

Participants completed informed consent prior to study procedures. Standard demographics, with a brief medical and falls history were collected prior to initiating the focus group. Ground rules were set such as one person speaking at a time and encouragement for all to engage and share their experiences and opinions. Beyond asking questions and clarification statements, the interviewers did not need to facilitate participants’ engagement in the groups as they were quite engaged in the process. Four focus groups of six to eight participants were conducted using the semi-structured interview guide (Table 1) with open-ended questions between December, 2019 and February, 2020. The primary investigator (a physical therapist with 20 years of experience and training in qualitative methods) conducted three of the four focus groups and a trained research assistant conducted one focus group. The research assistant received one-on-one training by the primary investigator and assisted with the other focus groups prior to conduction the last focus group. According to literature about gender differences in attitudes and beliefs,¹⁵ to encourage open participation two focus groups were formed consisting solely of women, and two focus groups consisting solely of men. Two focus groups were conducted in a conference room at a university, one was in a conference room at a senior center, and one was hosted at the house of a participant per their request. The focus groups lasted from 1 hour 18 minutes to 1 hour 29 minutes. Participants received a $30 Walmart gift card for participation in the interview. Focus groups were recorded on a digital voice recorder (Olympus WS-853, Olympus America, Inc, Center Valley, Pennsylvania).

Data analysis

Audiotaped interviews were uploaded to computerized software (Descript, San Francisco, CA) for initial transcription. A trained research assistant transcribed, then reviewed and edited all audio and transcriptions for accuracy. Data were analyzed using a Phenomenological Thematic Analysis Methodology to identify, analyze, and interpret meaning and themes in the data.¹⁶ Analysis began with a thorough reading of all transcripts. Reliability was ensured by having two coders with expertise in falls prevention separately code and analyzing the data. Transcripts were read a second and third time and identification of patterns was initiated. Through repeated reading, important ideas were marked for initial coding. A line-by-line analysis of the data was undertaken to identify important words or phrases and initial descriptions or codes of these narratives were applied. Line by line analysis also allowed for comparison of new data with data that had been previously described. Repeated patterns in the data were then identified. Data was labeled using in vivo codes or words that reflect understanding of the data. A table of initial codes was created, and the most significant or frequent codes were then collated and sorted into potential themes. During the final step of the analysis, researchers came to consensus on interrelationships between codes and core themes. After themes were identified, data narratives were selected to illustrate, explain, and support them. An audit trail of the raw data, interview transcripts, data reduction and analysis, and methodological notes was maintained. Peer examination of the coding was provided by the two researchers with experience in falls prevention among older adults and further review by an experienced qualitative researcher. All researchers agreed that data saturation was obtained with the four focus groups, that is, that no new ideas were forthcoming. Through prolonged immersion with the data, older adults’ perceptions of the role of PTs for falls prevention emerged.

Qualitative standards for rigor

In qualitative research, rigor is assessed through credibility, transferability, dependability, and confirmability.¹⁷ To increase credibility, a member check or debrief at the end of each focus group was conducted; concepts were summarized and feedback was requested from participants to validate the findings. To address transferability, readers were provided with detailed descriptions of the context to inform the findings. To ensure consistency, a semi-structured interview guide was followed (Table 1). To ensure confirmability, the extent to which findings reflect the participant’s reality, verbatim narratives were recorded and bracketing of quotes was used to increase objectivity. Detailed field notes and record keeping also provided an audit trail to ensure confirmability of data.

RESULTS

Sample Description

Table 2 summarizes the participant demographics, comorbid conditions, medications, and experiences of falling. Participants (n=27) averaged 78 years of age (range: 65–99 years), with about even distribution of males and females and the majority of participants were married. The study participants were all independent, community-dwelling, and arrived to the focus groups without any assistive devices. Ten participants (37%) experienced a fall in the last year and 26% reported suffering an injury from a fall. Participants in the focus groups were engaged and collectively accepting of others’ ideas. Personal experiences dominated the discussion.

Table 2.

Participant Characteristics

Characteristic	N (27)
Sex
Male	13
Female	14
Age
Male	79.4
Female	76.1
Race/Ethnicity
Non-Hispanic - white	21
Did not state	6
Educational level
Less than a high school diploma	2
High school degree or equivalent (GED)	0
Some college, no degree	11
Associate degree	2
Bachelor’s degree	5
Master’s degree	3
Professional degree (MD, DDS, DVM)	0
Doctorate (PhD, EdD)	2
Did not state	2
Yearly income
Less than $20,000	3
$20,000 to $34,999	6
$35,000 to $49,999	2
$50,000 to $74,999	5
$75,000 to $99,999	7
Over $100,000	3
Did not state	1
Marital Status
Married, or in a domestic partnership	19
Widowed	8
Comorbid conditions
Hypertension	7
Musculoskeletal impairments (low back pain, knee pain)	6
Cardiovascular disease	5
Arthritis	5
Hyperlipidemia	4
Vestibular impairment	3
Neuromuscular impairments (sciatica, fibromyalgia)	2
Thyroid impairment (hyper/hypothyroidism)	2
Enlarged prostate	2
Vision impairment (glaucoma, cataracts)	2
Depression	2
Cancer	1
Chronic obstructive pulmonary disease	1
Osteoporosis	1
Number of Medications
1–2	15
3–4	6
≥5	3
Did not state	3
Experienced a fall in the last year
Yes	10
No	17
Number of falls in the last year
1–2	4
3–4	2
≥5	1
Did not state	3
Falls resulting in injury
Yes	7
No	6
Did not state	14
Injury type from falls
Fracture	2
Musculoskeletal pain or soreness	3
Bruising or scrapes	3

Interview Themes

The analysis resulted in four main themes and five subthemes surrounding older adults’ perceptions regarding the role of PTs for falls prevention. Table 3 includes the themes, subthemes, and examples of representative quotes from the participants.

Table 3.

Overview of the Results: Overall Themes, Subthemes, and Exemplar Meaning Units

Overall Theme	Subtheme	Exemplar Meaning Unit
Awareness of Falls Prevention	I Can or Have Taken Action to Prevent Falls	“We all see these when we go in for a wellness visit annually or, or just to go see the doc and they update their paperwork and you know, it’s all nice to know, but I never hear a word about from, from my doctor or even the nurses. Where we see that you haven’t fallen, in the last year, but you know how to prevent falls. Well, here’s some things you could do, and then you go over this stuff. Like, you know, if you had some handrails in your shower, bath, tub area, ... hardwood floors with the throw rugs, you can buy this real cheap, easy to cut to fit knitting that goes under those things that will secure those throw rugs to hardwood floors. Just some simple preventing stuff. I don’t hear that. I don’t, know if anybody else does, but...” “You should always leave a light on in your bathroom. That’s so important. And then when you get up out of bed, not just rush to the bathroom. You got to sit on the bed for a few seconds.” “Don’t have any throw rugs laying around your home. ‘Cause you could trip on them... very very dangerous.” “We have handicap toilets... that few extra inches makes a big difference.”
Awareness of Falls Prevention	I Don’t Think About It	“Many of us have to experience failing at something before it gets our attention ... as we grow older, we don’t often recognize the changes physically ... and so we just do things, assuming that we can do it like we used to until we have a serious reminder, Hey, you can’t do that anymore. So better back up and look at it again.” ‘Until someone experiences a fall, they don’t think about it’
Awareness of Falls Prevention	I Am More Careful	“I take blood pressure medicine, and so I have to be real careful standing up.” “As you get older, you get more careful.” “One thing I’ve learned, I think as I’ve gotten older is not to get in a hurry doing something slow down.” “I have to just be, like everybody said, more cautious, more aware of the fact that I could fall.”
Learning How to Fall and Being Able to Get Up from the Floor	Not applicable	“I’ve got a friend ... every morning when he gets up, he sits on the floor about five or six times and gets up and he’s done it for years and he said it’s really helped him. I’ve been trying to do it, and it does.” “I was told by someone very much younger than me that her aunt told her, if you need to get up from the floor one day, practice getting down on the floor every day. Oh, you have to think about that for a minute. But, that makes sense because, when you fall, you’re in a panic. You forget how to do anything including get up. So, if you practice getting up, that might at least ease your panic A little bit.” “Now do you teach anything about like what you said when you do fall. Like do you turn a certain ways? ‘Cause many people cannot get up and if nobody’s there, I know when I fall and I couldn’t get up a few times. So, I just had to wait and then roll around a certain way where I could get to a chair or something to pick myself up. But if you have weak legs and you can’t get yourself up, what do you do, you just sit there, and die”
Limited Knowledge Regarding the Role of Physical Therapists for Falls Prevention	Not applicable	“I’m not here to say they’re not really asking or looking good. What else is happening? They’re just looking at his one little back problem, but I mean, you see a physical, you see a physical therapist is after the fact, not before the fact. I mean, we don’t usually go to a physical therapist for prevention.” “The physical therapist as an individual, is just concentrating on that one problem, a problem, a big problem, but it’s that one thing and they’re not really talking about other things like falling.”
Barriers to Seeking Treatment from a Physical Therapist for Falls Prevention	Perceived Need and Costs	“If you feel good, I don’t think if people would find the time to do it. If you didn’t feel you need it. I don’t think they would find the time.” “I think most insurance just are interested in prevention. And they pay pretty well on the actual, therapy. I think the real hindrance, and, I don’t know what to do about it, is just an inconvenience of coming and going, maybe, you know, if there was some way that somebody could come to your home and do the physical therapy.”
Barriers to Seeking Treatment from a Physical Therapist for Falls Prevention	Access Requires a Doctor’s Prescription	“You typically don’t go to just see a therapist unless you’ve been to a doctor and they say .... I’m going to refer you to physical therapy.” “Because of the fall prevention thing. I had it in my mind after that too. I was just telling [them] to go and get a referral ‘cause I do fall a lot. They went to get physical therapy and they’re working on my gait and balance and things. And I can tell, I mean, the exercises they’re having me do are great and there’s something you can do easily anywhere, you know?”

Theme 1 – Awareness of Falls Prevention

Analyses of the data indicated that most adults are aware of falls and prevention according to statements such as; “I’m more aware … I’m walking way around everything,”and “I think the older you get, you’re more aware. I’m more aware when I’m walking.” One participant suggested that awareness leads to action.

“The awareness is the beginning of all action… first have to be aware, and this would help bring awareness to the fact that, that, that you need to be sensitive to those possibilities and, and it would get you thinking. And so, it would initiate it, I think.”

Subthemes emerged. Some older adults do not think about falling while other older adults are aware of or take preventive measures to avoid falls, such as holding onto a rail on the stairs or wearing appropriate shoes. Older adults frequently discussed ways they were more ‘careful’ to prevent a fall. The majority of participants in each focus group mentioned the role of exercise and balance in falls prevention, generally, and sometimes more specifically, such as tai chi or yoga, but did not discuss these in detail.

Subtheme - I Can or Have Taken Action to Prevent Falls

When asked questions related to fall prevention, the majority of participants in each focus group were aware of or have taken action to prevent falls. For example,“I never go downstairs with both hands full. That is something I kind of do. It’s just in my mind to do it, you never know,” and, “I have grab bars in the bathrooms,” Others shared what they or other older adults could do to prevent falls; “Talk to your provider about your vision,” and “Older people know if they exercise, they’ll stay stronger.” Some participants more explicitly took action after they experienced a fall;

“I fell on the ice a few years ago and broke my shoulder… I didn’t wear the proper shoes outside. That was the problem. I had some little rubber shoes… I blame that on the kind of shoes, you know, that was stupid. It was bad weather…You have to make sure you have traction on your shoes”.

Subtheme - I Don’t Think About It

This subtheme indicates that many older adults only became aware of falls after they experienced one, not before. A common type of comment was, ‘Until someone experiences a fall, they don’t think about it’. Conversely, two participants indicated they do not worry about falling because they do not have a “problem”. Two other participants suggested that awareness of falling increases with frequency of falls; “I never thought about it until I actually fell, and then it kinda gets in the back of your mind”, and “I think the more we fall, the more aware we become.” One participant became more aware of falling after both he and his wife experienced falls and he helped his wife recover from a fall-related injury.

I fell a couple of times, but it was from doing stupid stuff like forgetting I had used a two step ladder to get up on the surface and then forgetting to step onto the ladder step and hitting thin air. But fortunately, I bounce, but I told my wife here not long ago after she broke her leg out in the garden. You know hun, the best thing we can do is to remember we’re not 40 years old. And, I try to think about that a lot when I’m out doing something, it’s real easy, you need to tackle this by yourself. And it kinda helps, It kinda slows me down a little bit. [I got to that point] by falling and taking care of her for 12 weeks, while her leg healed.”

Subtheme – I Am More Careful

The vast majority of participants indicated they became “more careful” as their primary way to prevent falls, with this being collectively and emphatically agreed upon across focus groups. Female participants reported being careful as a result of aging; “As you get older, you get more careful,” and, “I used to love to play with my grandchildren, but I have to be careful though, because even shooting a basket, could lose your balance, you know?” Male focus group participants were more calculated and cognizant of activities; “It gets down to using your head … you come to a point where [you think] hey, I better not be doing that” and “concentrate right before you do something.”

Theme 2 –Learning How to Fall and Being Able to Get Up from the Floor

Being able to get up off the floor is an unexpected theme that emerged from the data. As opposed to preventing a fall, a small minority of older adults in every focus group stated being proactive in their ability to be able to get up from the floor if they do experience a fall, either practicing getting down and up from the floor themselves or having friends who practice this activity.

“I was with my granddaughter and we were hiding from another granddaughter. Her sister, we knelt down by the car and she got up right away and I couldn’t get up. So I had to get on all fours to pick up my legs, you know? And she helped me with my arms, but it was so awful. I said, there’s gotta be a way to learn how to pick yourself up.”

“When we’re young, we get up and down on the floor. I started to do this again … I get down on the floor, so I have to get up because I remember my mom used to fall. She couldn’t get up, and my husband used to fall and he was sick. He didn’t have the strength to push himself up.”

This appeared to be a novel and intriguing idea to the majority of participants, which led to more discussion and interest in this topic. Three participants also stated they would be interested to “learn how to fall [and] learn how to get up”.

“This brought up just …a memory from like, I don’t know how many years. My mother decided she wanted to learn judo. She wanted me to go with her. You know, I don’t want to be that active, but I’ll go with you. And … the instructor said, the first thing I am going to teach you is how to fall. That’s the thing I learned in judo was how to fall.”

Those who did not mention this practice acted intrigued and thought this was a good idea.

Theme 3 - Limited Knowledge Regarding the Role of Physical Therapists for Falls Prevention

A main theme that emerged from the focus groups was lack of understanding that physical therapists can help an older adult to prevent falls. Although older adults felt that receiving care from a PT was efficacious for treating specific problems, they did not mention their perceptions regarding the role of PTs in regards to falls prevention until that targeted question was posed. Narratives exemplified this theme; “preventive, what would you go for?”, and “you don’t usually go to a physical therapist for prevention” “I don’t think of it as preventative as much as a treatment.” This lack of understanding expanded into subthemes. Participants largely felt that they should seek out care from a PT to treat a very specific problem, after a surgery, or after they experienced a fall. One participant stated why he would not just go to see a PT;

“Well, for me it would be very difficult unless I had an experience that I felt, hey I’ve got to go there … But if I don’t have any experience like that, it’s, I just stay away. I don’t go to physical therapy … [because] I don’t need it.”

Participants indicated they felt should seek treatment from a PT only after experiencing a fall. These perceptions were manifested in narratives such as; “A physical therapist is after the fact, not before the fact” “after, not before.” Another participant had similar feelings; “I think after a fall … physical therapy is after the fact… not preventive.” One participant felt that PTs can help prevent recurrent falls, but again did not mention the role of PTs in preventing a first fall;

“I mean that’s why I went over there ‘cause I thought, I know I’m going to fall again. So, it just seemed like it made sense… that’s why I wanted to do it because there’s still things I’d like to do in my young life and I want to be in shape to do it.”

The majority of participants cited they or their loved ones had positive personal experiences with PTs and that treatments provided by PTs were effective, but only appropriate to address a specific problem or after a surgery, not preventive. “My wife had experienced [frozen shoulder] and was greatly benefitted by physical therapy”. Another participant stated, “I’ve had physical therapy for my back issues and after I went to a session and I really believe in how much good it does. It did help me a lot.”

Overwhelmingly, participants believed they should only seek treatment from a PT for a specific problem. Exemplary statements included, “physical therapy is after … for the knee replacements” and “…not really talking about other things like falling.” These perceptions were further exemplified by personal experiences; “well … you have to go to a physical therapist right now for [your] back. So, they’re concerned about that problem…they’re concentrating on that one part.” One participant explained their experience with a PT; “the evaluation was very thorough, but they did all kinds of stuff, including a history of fall, any injuries and that kind of thing. But it didn’t go much farther than that.” Another participant felt that the PT is limited to “address only what is written [by the doctor].”

Even among participants who thought PTs could potentially help reduce risk for falls, most believed PTs could only do so after an initial injury or in conjunction with treatment for another condition. One participant commented: “It will, first of all, help with your pain, but make it more likely that you won’t fall.” Another had similar thoughts,

“I did have some back issues and, uh, some nerve damage with one of my legs. So, I went through some physical therapy and they gave me some exercises that I think it helped me make sure that I don’t, you know, try to avoid some falls.”

Only one participant suggested, “If there was a senior fair, physical therapy could teach you how to fall.”

Theme 4 - Barriers to Seeking Treatment from a Physical Therapist for Falls Prevention

Participants cited a number of barriers to seeking treatment from a PT for falls prevention. These included lack of perceived need, time costs, and misconceptions that a doctor’s prescription is required. One participant’s statement exemplified these themes;

“I think most of us, you know, physical therapy is not covered unless your doctor’s prescribed. I don’t think, for me it’s even a matter of cost. It’s just that I do, I don’t feel like I need it. But if you came to that, if I came to a point, I definitely, I wouldn’t just volunteer to go cause I don’t think I need it. But I’ve had, I’ve been, uh, I had a doctor, tell me to go to it because, I can’t even remember the reason for it now, but I did. “

Subtheme - Perceived Need and Costs

Time costs and a lack of perceived urgency or need were major reasons that participants did not seek a PT for falls prevention. One participant who screened positive for fall risk in a community event stated unequivocally that he,

“… went through a balance test. I miserably failed. I asked [a person] to give me the number of a physical therapist who knew about falling…. She gave me the phone number. Well, I hadn’t called it… it wasn’t a convenient time for me to start all that.”

Many participants noted that lack of obvious symptoms may reduce perceived urgency of seeking care from a PT, stating, “If you feel good, I don’t think people would find the time to do it. If you didn’t feel you need it. I don’t think they would find the time.” Participants also felt the cost of seeing a PT for falls prevention may outweigh the perceived benefits. One participant commented, “I mean, even with copays, you know, your insurance will pay for some of it, but still. I mean, it’s worth it if you figure what it’s doing for you. But it is expensive.” One even felt like simple brochures describing the exercises was sufficient, “A lot of it can be a little brochure telling me what I need to do, and I can do it at home and not make these expensive trips.”

Subtheme – Access Requires a Doctor’s Prescription

Many participants believed that a doctor’s prescription is required in order to be seen by a PT, “You typically don’t go to just see a therapist unless you’ve been to a doctor and they say …. I’m going to refer you to physical therapy.” Insurance coverage of preventive services was similarly tied to a doctor’s prescription in the minds of the participants, with one positing that, “Physical therapy is not covered [by your insurance company] unless your doctor has prescribed it.”

DISCUSSION

This study is the first, to our knowledge, to describe older adults’ awareness and perceptions regarding the role of PTs in the prevention of falls and the barriers to these older adults’ seeking treatment from a PT for falls prevention. Focus group interviews indicated that some older adults are unaware that falls are a major health risk to older adults, while others are keenly aware and employ measures to prevent falling, such as environmental modifications and physical activity. Many participants mentioned being proactive and practicing getting on and up from the floor in case they do experience a fall. However, all participants perceived the role of a PT is only to address a problem, specific diagnosis or injury, or for after a fall. There was an overall lack of awareness that PTs can assist older adults to prevent falls. Additionally, older adults stated possible barriers to seeking treatment from a PT for falls prevention including concerns regarding costs, time and convenience, and perception that a doctor’s prescription is required in order to be seen by PT.

The results of our study align with previous research indicating that some older adults do not think about falling while other older adults are aware of various prevention measures, such as environmental modifications, appropriate footwear, and exercise.^18–21 The majority of participants also indicated they are more ‘careful’ or ‘cautious’ and calculate the risk of an activity, which also aligns with previous literature.^22,23 Of interest, 37% of our participants experienced a fall in the last year and 26% reported suffering an injury from a fall, which likely impacted their awareness of falls and prevention. However, our participants’ lack of awareness that PTs are recommended and capable of assisting an older adult to prevent falls is a novel finding. No studies we found investigated older adults’ knowledge or awareness of PTs for falls prevention; despite the CDC⁷, USPSTF⁸, and APTA⁶ recommending PTs roles in primary, secondary, and tertiary prevention of falls. Specifically, the APTA’s clinical guidance statement asserts that PTs should screen all community-dwelling older adults for fall risk, and conduct assessments and provide interventions for older adults at-risk.⁶ This is especially important considering that older adults at high risk of falls are 3-times more likely utilize rehabilitation services,⁹ additionally Healthy People 2030 objectives include reducing falls, their consequences, and fall-related deaths.⁴ The mismatch between professional recommendations and older adults’ lack of awareness of the role of PTs for falls prevention is potentially harmful, as older adults may not seek care even when educated about fall risk, leaving them vulnerable to future falls. There appears to be a major gap in older adults’ knowledge of PT’s role in fall prevention and society’s dissemination of the role of PTs in the prevention of falls.

Our study findings add clarity to prior investigations indicating underutilization of rehabilitation services among older adults at risk for falls. Gell et al.⁹ analyzed data from the 2015 NHATS and found that only 14% (N = 7487) of the representative sample of Medicare beneficiaries cited falls as the primary reason for attending rehabilitation. Using this same data set, Gell et al. found that only 12.6% of older adults at moderate risk and 34.7% at high risk had falls addressed explicitly during rehabilitation. Similarly, McDonough et al.²⁴ investigated procedural codes among over 300,000 Medicare beneficiaries who sustained an upper extremity fracture and found that less than 20% of older adults who underwent rehabilitation for the fracture also received an evaluation or treatment related to falls risk, despite the fact that falls are the leading cause of fracture. These studies are consistent with our findings that older adults do not perceive one of the roles of PTs includes falls prevention and therefore, older adults do not seek out a PT for falls prevention. This is concerning considering that falls are the leading cause of injury-related mortality among older adults and many falls are preventable.¹

Our results indicate that older adults perceive they should only seek out a PT if they require treatment for a specific problem, not for falls prevention. Results from the NHATs rehabilitation utilization study by Gell et al.⁹ add further clarity to our results. Although less than 35% of older adults at moderate and high risk of falls reported their goal for rehabilitation was to address falls, 45.0% of adults at moderate risk and 57.2% of older adults at high risk reported balance and coordination as goals of treatment. These data indicate that older adults are receiving interventions to address impairments that are risk factors for falls; however, they may not be receiving explicit information on falls prevention. It is important to note that, although the CDC⁴ and the USPSTF⁸ assert PTs’ roles in falls prevention among older adults identified at risk, PTs can and should screen, assess, and intervene for primary prevention of falls among all older adults (regardless of the reasons they are attending physical therapy) per clinical guidelines.⁶ Older adults’ perceptions and underutilization of rehabilitation services for falls prevention indicates PTs may be missing a valuable opportunity to explicitly screen and educate older adults on falls prevention.

The primary barriers to older adults’ seeing a PT for falls prevention that were identified in our study included lack of awareness that PTs can provide fall prevention and a lack of perceived need to see a PT for fall prevention. Similarly, perceived need and relevance were related to older adults’ participation in falls prevention interventions in a systematic review.²⁵ In the HBM, awareness and perceived need contribute to an individual engaging in a health behavior. PTs should address older adults’ lack of awareness that PTs can assist an older adult to prevent falls to promote engagement in fall prevention activities. Other barriers to seeing a PT were similar to those identified in the literature; including insurance coverage, cost, and convenience.²⁶

Capitalizing on older adults’ perceptions about falls and prevention may serve as facilitators to increasing older adults’ utilization of PTs for falls prevention. For example, many older adults in our study who had seen a PT, regardless of the reason, indicated that physical therapy services were positive, effective, and useful. These perceptions align with results from the aforementioned study by Gell et al.²⁴ on rehabilitation utilization and patient-reported outcomes; where 72% of older adults attending rehabilitation reported functional improvement and 75% reported meeting their goals by discharge.²⁷ PTs need to communicate their role and in falls prevention to older adults and other healthcare providers. Increasing public awareness of PTs role in falls prevention may also help to increase the number of older adults who are screened and receive appropriate interventions for falls prevention, thereby preventing some falls among older adults.

Older adults’ interests in learning how to fall and being able to get up from the floor was an unexpected theme. This awareness may be influenced by older adults’ desire for independence and self-sufficiency and the many commercials advertising devices for fall alerts.²⁸ This theme aligns with the HBM where cues to action may trigger behavior change, for example, the commercial serves as a cue to action, leading to older adults’ increased awareness of falls and their interest in learning how to get up from the floor.¹⁴ This cue could serve as a facilitator to increasing the awareness and utilization of PTs for falls prevention; PTs are encouraged to take advantage of older adults’ interests in the importance of being able to ‘get up from the floor’. Although ability to perform a floor transfer is not preventive of fall, this functional task is highly correlated with outcomes measures related to falls risk, such as gait speed and the Timed Up and Go.²⁹ Additionally, older adults who are unable to perform a floor transfer are more likely to have a history of falling and require assistance with activities of daily living compared to older adults who are independent with floor transfers.³⁰ Therefore, it is suggested that floor transfer ability should be a standard component of a geriatric functional assessment³⁰ and a possible transition into more explicit falls prevention engagement.

Strengths and Limitations

Common limitations of qualitative research are present in the study. For example, there is some degree of interpretation of results inherent in the qualitative analytic process. However, direct quotes are provided to the readers to provide context and confirmability. The fact that the interviewers were PTs may have biased the participants to answer more positively about their perceptions of physical therapy. Another limitation includes the small, self-selected convenience sample of older adults representing a small geographic area that may not be generalizable to the overall US population.

Strengths of our study include the novelty of our aim to determine older adults’ perceptions regarding the role of PTs for falls prevention. Results regarding participants’ awareness and perceptions about falls prevention in general align with previous studies; supporting that the results regarding their perceptions regarding PTs for falls prevention may be generalizable. Additionally, alignment of our study participants’ perceptions with rehabilitation utilization data further make our findings more generalizable.

CONCLUSION

The results of this study suggest that older adults lack overall awareness about the role of PTs specifically for falls prevention. Older adults perceive PTs only treat a specific problem, and should not be seen for falls prevention. The reason for this misconception was not investigated in this study. Per CDC recommendations and other guidelines, all healthcare providers (including PTs) should address falls prevention with all older adults. Being explicit about the prevention of falls throughout an older adults’ episode of care may help reinforce the role regarding PTs in falls prevention and improve public dissemination of this knowledge.

PTs may be able to capitalize on older adults’ experiences and perceptions that PTs effectively address different problems and therefore, can address falls prevention. Additionally, PTs may consider implementing floor transfers into their geriatric assessments as a determination of falls risk and an opportunity to discuss falls prevention. PTs and the profession should consider addressing misconceptions and underutilization regarding falls prevention by educating the public and stakeholders that PTs can and do play an important role in the prevention of falls, even beyond addressing direct impairments.

Future studies should investigate the gap in rehabilitation utilization for falls prevention using mixed methods to explain the quantitative data at both the provider- and patient-levels, including PTs knowledge and clinical implementation of falls prevention. Other research would be beneficial to determine the impact of PTs promoting their roles for falls prevention and the influence on society. Additionally, replication of this qualitative investigation among people with different races and ethnicities would also be beneficial to discern any disparities and promote generalizability.