What are the recommended handicap provisions for a patient with instability, history of falls, chronic back pain, and use of assistive devices (AD) for ambulation in their home?

Home Handicap Provisions for Patients with Instability, Falls, Chronic Back Pain, and Assistive Device Use

For patients with instability, fall history, chronic back pain, and assistive device dependence, implement a multifactorial home modification program including: gait training with appropriate assistive devices, environmental hazard reduction (grab bars, non-slip surfaces, removal of tripping hazards), medication review focusing on psychotropic agents, and consideration of wheelchairs for those with limited walking ability—all components shown to reduce falls and improve safety when combined. 1

Assistive Device Selection and Training

Primary Mobility Devices

• Ambulatory assistive devices (canes, walkers) should be prescribed to improve gait, balance, and mobility safety when patients demonstrate instability or fall risk 1
• Walkers provide superior stability compared to canes for patients with bilateral lower limb weakness or poor balance, offering a larger base of support 2
• Two-wheel rolling walkers are more functional than standard walkers, while four-wheel rollators suit higher-functioning individuals who need rest breaks but maintain better balance 2
• Canes are the least stable assistive device and require sufficient upper body strength, balance, and dexterity—they should be held contralateral to the weak or painful limb 3

Wheelchair Considerations

• Wheelchairs should be prescribed for nonambulatory individuals or those with severely limited walking ability who cannot accomplish mobility-related activities of daily living 1, 4
• Power wheelchairs with positioning features increase participation and improve quality of life in community-dwelling individuals with severe mobility limitations 4, 5
• Motorized scooters are NOT appropriate substitutes for power wheelchairs in patients with instability or fall history, as scooters require preserved upper body strength, balance, independent transfer ability, and hand-motor coordination for brake management on slopes 5
• Proper wheelchair sizing and patient education are essential to avoid skin breakdown 2

Orthotic Devices

• Ankle-foot orthoses (AFOs) should be used for ankle instability or dorsiflexor weakness to improve gait and prevent falls 1
• Lower-extremity orthotic devices should be considered if ankle or knee stabilization is needed 1
• Initially use prefabricated braces; reserve customized orthoses only for patients demonstrating long-term need 1

Environmental Home Modifications

High-Priority Modifications for Fall Prevention

Home fall-hazard reduction interventions reduce the rate of falls by 38% in patients selected for higher fall risk (those with fall history, recent hospitalization, or requiring support with daily activities) 6

• Install grab bars in bathrooms near toilets and in showers/tubs 1
• Apply non-slip strips on steps and use nonskid mats 6
• Remove tripping hazards including loose rugs, clutter, and electrical cords 1, 6
• Ensure adequate lighting throughout the home, particularly in hallways and stairs 1
• Install elevated toilet seats to reduce fall risk during transfers 1
• Provide tub and shower chairs for bathing safety 1

Timing and Implementation

• When patients at increased fall risk are discharged from hospital, a facilitated environmental home assessment should be conducted 1
• Home modification programs are effective in reducing falls when part of a multifactorial intervention, but show no benefit when implemented in isolation without addressing other risk factors 1, 6

Medication Management

Patients with fall history should have comprehensive medication review with particular attention to psychotropic medications and polypharmacy 1

• Reduction of medications is beneficial in patients taking four or more preparations 1
• Psychotropic medications (neuroleptics, benzodiazepines, antidepressants) show consistent association with falls across all settings 1
• Manage postural hypotension as part of fall-reducing interventions 1
• For chronic back pain, nonsteroidal anti-inflammatory drugs are the initial medication of choice; avoid long-term opioids 7

Exercise and Physical Therapy

Older people with recurrent falls should be offered long-term exercise and balance training 1

• Balance training is a critical component of effective fall prevention programs 1
• Gait training and advice on appropriate assistive device use should be provided 1
• Tai Chi shows promise as balance exercise but requires further evaluation 1
• Patients should participate in regular strengthening and aerobic programs designed with consideration of comorbidities and functional limitations 1

Adaptive Equipment for Daily Activities

Adaptive devices should be used for safety and function when other methods of performing tasks are unavailable, cannot be learned, or when patient safety is a concern 1

• Long-handled sponges for bathing 1
• Hand-held showers 1
• Eating utensils with built-up handles, rocker knives, plate guards 1
• These devices supplement but should not replace patient mastery of tasks 1

Critical Pitfalls to Avoid

• Do not prescribe assistive devices in isolation without addressing other fall risk factors—they are effective only as part of multifactorial interventions 1
• Avoid bed rest for patients with chronic back pain 7
• Do not substitute motorized scooters for power wheelchairs in patients with instability, as scooters are less stable and cannot accommodate complex seating needs 5
• Ensure assistive devices are properly sized: the top of canes or walkers should align with wrist crease when standing with arms relaxed 3
• Verify that patients receive instruction on proper assistive device use—most patients with assistive devices have never been properly instructed and often have inappropriate or incorrectly sized devices 3

Follow-Up and Monitoring

• Patients require follow-up with primary care provider within one month of discharge 1
• Those receiving rehabilitation services need follow-up with rehabilitation professionals 3-6 months after discharge 1
• Routinely evaluate assistive devices to ensure proper height, fit, maintenance, and correct use 3
• Provide home exercise programs or refer to appropriate community exercise programs 1