10.3 Geriatric Physical Therapy, Sarcopenia, and Fall Prevention
Key Takeaways
Assess lower-limb power, sensory function and the response to standing in the context of the patient’s symptoms and tasks.
Under EWGSOP2, low strength suggests probable sarcopenia. Low muscle quantity or quality confirms it, and low physical performance establishes severe sarcopenia when the first two criteria are met.
A DXA T-score of −2.5 or below at a valid diagnostic site can establish densitometric osteoporosis in postmenopausal women and men aged 50 and over. Fracture history guides exercise precautions and referral.
The Fried phenotype uses unintentional weight loss, exhaustion, low activity, slowness and weakness. Three or more features meet the phenotype.
Use mobility and balance tests to identify problems to address. Falls history, clinical findings and home circumstances guide assessment and prevention, including progressive strength and balance exercise.
Geriatric Physical Therapy, Sarcopenia, and Fall Prevention
Age-Related Physiological Changes
Assess how changes in force, sensation and tolerance of upright activity affect the tasks the person wants to do. Avoid prescribing by chronological age alone. An older adult who cannot rise without the arms may need a higher chair for training, while someone who rises easily but becomes lightheaded needs attention to the upright response before walking.
- Neuromuscular. Muscle size, force and power can decline with age. Studies of older muscle have found a loss of fibers and a reduction in the size of some fast-twitch fibers. Clinically, power matters for getting up from a low chair, climbing a step or recovering with a quick step. Start with a height, resistance and level of support the patient can control and progress from that baseline.
- Sensory. Vision, somatosensation and vestibular information contribute to postural control. Reduced visual contrast, reduced foot sensation or impaired vestibular function may be more apparent during a dimly lit turn or on an uneven surface than in a well-lit clinic. Test relevant tasks safely and consider vision, foot and vestibular assessment when indicated.
- Cardiovascular and autonomic. Check exertional symptoms, medication effects and postural symptoms. With suspected orthostatic hypotension, record blood pressure and pulse after five minutes supine and again at one and three minutes after standing, with assistance as needed. Classic orthostatic hypotension is a sustained decrease of at least 20 mmHg systolic or 10 mmHg diastolic within three minutes of standing. Symptoms can accompany the drop but are not required for that definition. A concerning symptom history warrants follow-up even when a brief office test is negative. Avoid unguarded walking while the patient is symptomatic and coordinate evaluation of medications or other contributors with the medical team.
Sarcopenia and Dynapenia
Dynapenia describes age-related loss of strength or power. It can occur with or without a measured loss of muscle quantity. Sarcopenia is a disorder of skeletal muscle. EWGSOP2 uses strength to identify probable sarcopenia, then assesses muscle quantity or quality for confirmation and physical performance for severity.
| EWGSOP2 step | Interpretation and examples |
|---|---|
| Identify low strength | Probable sarcopenia. Example cut points are grip strength below 27 kg in men or 16 kg in women, or more than 15 seconds for five chair rises. Use the intended test protocol and consider pain, neurological weakness or other factors that limit the result. |
| Check muscle quantity or quality | Low quantity or quality confirms sarcopenia when strength is low. For quantity, DXA or appropriate bioimpedance can estimate appendicular skeletal muscle mass (ASM). Example low ASM thresholds are below 20 kg in men or 15 kg in women, or below 7.0 and 5.5 kg/m² respectively when divided by height squared. |
| Check physical performance | Poor performance indicates severe sarcopenia when the diagnosis is already confirmed. EWGSOP2 examples include usual gait speed of 0.8 m/s or less, Short Physical Performance Battery score of 8 or less, or TUG of 20 seconds or more. This TUG cut point is specific to the EWGSOP2 performance criterion. |
For example, a man who grips 22 kg and walks at 0.72 m/s has low strength and poor performance by these cut points. His diagnosis is still probable until low muscle quantity or quality is established. With DXA-derived ASM/height² of 6.4 kg/m², he meets all three criteria for severe sarcopenia. Plan progressive resistance and functional practice, and coordinate nutritional or medical assessment when poor intake, unintended weight loss or contributing illness is suspected.
Osteoporosis and Exercise
A T-score expresses bone mineral density in standard deviations relative to a young adult reference. In postmenopausal women and men aged 50 and over, ISCD permits densitometric diagnosis from valid central DXA measurements at the lumbar spine, total hip or femoral neck. The WHO international reference site is the femoral neck. In selected circumstances, the 33% radius may be used. A hip T-score uses a young adult female reference for both sexes under ISCD positions.
| T-score | Densitometric category |
|---|---|
| −1.0 or higher | Normal |
| Between −1.0 and −2.5, excluding both endpoints | Low bone mass |
| −2.5 or lower | Osteoporosis |
Fracture probability also depends on clinical factors, including prior fragility fracture. The 2023 Saudi Osteoporosis Society update recommends screening Saudi women and men aged 60 and over and selected younger people with risk factors, such as fragility fracture in women aged 40 and over. Coordinate fracture risk and medical treatment assessment according to the Saudi clinical pathway and local service. Apply the appropriate interpretation for younger adults, where Z-scores are usually preferred.
Use progressive resistance, balance work and suitable weight-bearing activity. A person with poor balance may need supported step practice before more demanding weight-bearing exercise. Train spinal extensor endurance and a hip hinge for bending and lifting. Modify loaded, repeated or end-range spinal flexion, especially with vertebral fracture. For example, replace loaded end-range sit-ups with a trunk exercise the patient can perform without marked spinal flexion. After vertebral fracture or multiple low-trauma fractures, the UK exercise consensus generally limits impact to the equivalent of brisk walking unless a clinician provides individualized guidance. Begin below that level if function or symptoms require it. New severe spinal pain after low trauma warrants assessment before progressing exercise.
Fried Physical Frailty Phenotype
The original Fried phenotype uses five features: unintentional weight loss, exhaustion, low activity, slow walking and weak grip. At baseline, the original study asked about more than 10 lb of unintended weight loss in the prior year. It used sex- and height-specific criteria for slowness, and sex- and BMI-specific criteria for grip weakness. Use the operational criteria for the chosen version rather than applying one grip or walking threshold to every patient.
Three or more features meet the phenotype, one or two indicate an intermediate or prefrail state, and zero indicate absence of the measured phenotype. Frailty and sarcopenia can coexist. An assessment can use the phenotype to investigate reserve and vulnerability and use the sarcopenia criteria to answer a separate muscle-related question.
Falls Assessment in the Community
Ask about the number and timing of falls, activity at the time, injuries, symptoms, possible loss of consciousness and whether the person could get up without help. Review walking aid use, footwear, medications, vision, dizziness and home hazards. Consider new or unexplained symptoms for medical assessment.
UK NICE NG249 advises against falls risk prediction tools. In its community pathway, offer comprehensive falls assessment and management to a person who has fallen in the past year and has any of the following: frailty, an injury requiring medical treatment, fall-related loss of consciousness, inability to get up independently, or two or more falls in the last year. For a person with a fall in the past year and none of those features, assess gait and balance. If impaired, offer falls prevention exercise and consider a home hazard assessment. This pathway uses the history to determine the next step.
US CDC STEADI uses functional tests as part of screening, assessment and intervention. The protocols can describe modifiable mobility, balance and strength problems. Keep the intended setting and purpose in mind when interpreting a score.
| Test | What to observe and how to use it |
|---|---|
| Timed Up and Go | Time standing from an armchair, walking 3 metres, turning, returning and sitting at the person's usual pace. Note the device and movement quality. STEADI uses 12 seconds or more as a screen finding. |
| Berg Balance Scale | Fourteen tasks, scored 0–4 each, total 0–56. Review which tasks were difficult. A score by itself cannot decide independence, need for an aid or who will fall. |
| 30-Second Chair Stand | Under STEADI, use a 17-inch armless chair and arms folded across the chest. Count completed stands according to the protocol and use the age- and sex-specific reference. If arm use is necessary, record 0 under the standard protocol and document the adaptation separately. |
| Four-Stage Balance Test | Progress from side-by-side to semi-tandem, tandem and single-leg stance. Guard closely, use eyes open, and progress only after a 10-second unsupported hold. In STEADI, inability to maintain tandem for 10 seconds is a screen finding. |
A comprehensive assessment is broader than these tests. It can include strength, gait and balance, orthostatic blood pressure, vision, foot health, medications, cognition, continence, home hazards and concerns about falling. Choose tests and referrals based on what the history and examination indicate.
Environmental and Exercise Intervention
Ask where and when the person fell, what they were doing and what footwear they used. A validated home hazard assessment by a trained professional can support practical changes. Improve lighting on frequently used routes, secure loose rugs or cords, check handrails and fit bathroom supports where needed. Practise using the walking aid on the routes the person needs. Where safe and appropriate, practise getting up from the floor or agree on how to summon help after a fall.
For older adults, WHO recommends working toward 150–300 minutes of moderate aerobic activity weekly, 75–150 minutes of vigorous activity or an equivalent combination, with major muscle strengthening at least two days weekly. Its older adult guidance includes multicomponent activity emphasizing functional balance and strength at moderate or greater intensity on at least three days weekly. Begin at a feasible level and progress according to ability, comorbidities and symptoms.
The Otago Exercise Programme is an example of individually prescribed home exercise. The original manual offers five lower-limb strengthening exercises and twelve balance exercises. Examples include knee extension with ankle weights, heel raises, supported tandem stance and sit-to-stand. A trained provider selects exercises and progresses support, repetitions or resistance after checking safety and technique. The manual schedules strength and balance exercise about three times weekly and walking at least twice weekly if safe, with home instruction and follow-up. Walking complements the balance and strength exercises.
Worked Case: Two Falls and Lightheadedness
A 79-year-old reports two falls within six months, one while turning in a dim hallway and another soon after getting up at night. She has known osteoporosis and completes TUG in 16 seconds with her cane, taking extra steps to turn. Her Berg score is 42/56, with difficulty reaching and turning, and her grip strength is 14 kg. The grip result meets the female low-strength criterion for probable sarcopenia. A diagnosis still requires evidence of low muscle quantity or quality. On guarded measurement after five minutes supine, blood pressure is 136/82 mmHg. At one and three minutes standing it is 114/72 mmHg, with lightheadedness. The sustained fall is 22 mmHg systolic and 10 mmHg diastolic, meeting the classic orthostatic criterion. The measurements warrant follow-up but cannot identify the sole cause of either fall.
Under the NICE community pathway, two falls in a year warrant comprehensive assessment and management. Address upright symptoms and coordinate medical and medication review, examine the home route and lighting, and train safe transfers, turns and lower-limb strength using appropriate support. Review fracture history when choosing the balance and strengthening tasks. Show how to pause and steady herself during position changes and have her demonstrate the strategy before attempting unguarded use. At follow-up, document the timing and circumstances of any falls and repeat relevant functional tests in the same conditions. Better turning in the clinic supports progression of task practice. The patient's report of turning at home and standing safely also matters.
A 72-year-old man has DXA-derived appendicular muscle mass divided by height squared of 6.4 kg/m², grip strength of 22 kg, and usual gait speed of 0.72 m/s. Which classification meets EWGSOP2 criteria?
Probable sarcopenia only, because gait speed is not used in this framework.
Confirmed sarcopenia with no evidence of poor performance.
Severe sarcopenia, because strength, muscle quantity and physical performance are all low.
Low muscle quantity only, because grip strength of 22 kg is above the male threshold.
A 68-year-old woman has lumbar and femoral-neck T-scores below −2.5 and a prior vertebral fragility fracture. Which proposed exercise should be modified first because it repeatedly loads the spine in marked flexion?
A supported sit-to-stand from a chair of suitable height.
A supervised low-load back extensor exercise.
A short, level walk at her tolerated pace.
Repeated weighted sit-ups through end-range spinal flexion.
An 81-year-old community-dwelling adult reports two falls in the past year. TUG takes 13 seconds and BBS is 48/56. Under NICE NG249, what should the physiotherapist do?
Offer comprehensive falls assessment and management. Use the observed task performance to identify possible intervention targets.
Use the BBS result to conclude that the patient has no further fall-related needs.
Repeat TUG until it exceeds 20 seconds before assessing other factors.
Assign a probability of an individual fall by combining the two scores.
A physiotherapist plans to use the original Otago Exercise Programme with a 78-year-old who lives at home. Which plan reflects the programme?
Unsupervised walking only, progressing duration regardless of symptoms.
Individually selected progressive lower-limb strengthening and balance exercises with home instruction and follow-up, plus walking when safe.
An identical set of advanced balance exercises with no progression for every participant.
Passive range of motion and stretching with no strength or balance practice.
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