Case Study: 65-Year-Old Male – Fall Incident During Physical Therapy

Background

A 65-year-old male, one year post-CVA (cerebrovascular accident), suffered a fall while participating in physical therapy. The incident raised concerns about the therapist’s approach to balance training and assistive device reduction.

Patient Information

• Age: 65 years
• Gender: Male
• Medical History:
• CVA (1 year ago)
• Right-sided hemiparesis and foot drop secondary to CVA
• Right AFO (Ankle Foot Orthosis) for foot drop
• Hypertension, hyperlipidemia
• Mobility:
• Ambulates with a single-point cane and right AFO for support

Presenting Condition

The patient had residual right-sided weakness and foot drop, requiring an AFO and a single-point cane for mobility. His rehabilitation program included balance training, gait retraining, and lower extremity strengthening to improve independence.

Physical Therapy Program

The therapy program aimed to enhance balance, strength, and walking ability. Key components included:

• Balance exercises to improve postural control and proprioception
• Gait training to enhance foot clearance and weight shifting
• Strengthening exercises for motor function improvement
• Progressive reduction of assistive devices to encourage independent ambulation

The therapist's goal was to wean the patient off his AFO and cane to improve his mobility and functional independence.

Challenge: Fall Incident in Therapy Gym

During a balance and ambulation exercise, the therapist instructed the patient to walk without his AFO, cane, or physical assistance. While practicing weight shifting and foot clearance, the patient’s right foot caught on the floor during push-off, causing him to lose balance and fall. He sustained a right hip fracture.

Key Issues Identified:

• The AFO and cane were removed simultaneously, increasing the patient's fall risk.
• The therapist did not provide manual or physical support, leaving the patient vulnerable to balance loss.
• The patient’s functional readiness was not adequately assessed before progressing to unsupported walking.

Solution & Results

The primary concern in this case was the therapist’s decision to advance treatment without appropriate safeguards. Best practices suggest:

✔ Gradual reduction of assistive devices rather than removing both at once.
✔ Providing hands-on support or a safety harness during balance and gait training.
✔ Assessing the patient’s readiness for unsupported ambulation with structured progression.

By following evidence-based protocols, similar incidents can be prevented, reducing the risk of falls and potential legal consequences for improper therapeutic progression.

Lessons Learned

Clinical Takeaways:

• Assess functional ability before removing assistive devices.
• Introduce changes gradually to ensure patient safety.
• Provide manual support when reducing external aids.

Legal Implications:

• The therapist may be found negligent for failing to provide necessary support.
• Progressing therapy too quickly without considering fall risk can result in liability.