*September 23, 2019 is annual Falls Prevention Awareness Day

What comes to mind when you think about patient safety in a physical therapy rehabilitation or recovery facility or nursing home? How to best prevent injuries, especially injuries from falls right?

Falls are the worst and the costliest threat to rehabilitation or PT patients. On average, the hospitalization cost for a fall injury is over $35,000 (National Council on Aging), and the American Physical Therapy Association (APTA) reports falls Among US Adults 65 and Older Cost $50 Billion in 2015.

Much has been written and researched on fall prevention. There are chapters and books and scholarly articles all saying the same thing – falls among older adults are expensive and debilitating, and often preventable.

Fall prevention is possible with patient education, environmental restructuring, attention to care plans where improvement is needed, and a concerted effort to reduce the identified functional limitation of the patient based on any number of evaluation tools.

But what if that’s not happening the way it should be?

I’ve personally seen physical therapists fail to close guard – risking injury to themselves and the patient.

Whether in hospital rehab or outpatient physical therapy, I have seen therapists not providing a close guard to patients. I perceive (and research supports) that the lack of close patient guarding has become more prevalent in the past 10 years.


And the experts agree. Approximately one in four U.S. residents aged ≥65 years (older adults) report falling each year. Documentation stresses multitasking and conversational distractions may reduce a therapist’s vigilance on a close guard.

Some startling statistics about healthcare worker and patient injuries:

  • Healthcare workers account for 20% of all nonfatal occupational injuries across the United States (Centers for Disease Control 2015) and that healthcare workers are still number one when it comes to on-the-job injuries.
  • Patient handling is the number-one reason for workplace injury among nurse assistance and rehab staff and that patient handling injuries have been on the rise since 2014 (The Occupational Health Safety Network).
  • The estimated one-year work related injury rate for physical therapists is 20.7% (Physical Therapy Journal, 2014).
  • The overall rate of older adult deaths from falls increased 31% from 2007 to 2016 (CDC).

Even I was surprised at the data – nearly a 21% injury rate per year in my field – probably higher in 2019!

A close guard is essential for when a patient is struggling with or unsure of their balance. If a therapist isn’t close by, the patient can quickly go past the “point of no return” and patient and therapist may be injured in the attempt to avoid a fall.

It seems a simple enough dilemma, but I would estimate that one third of therapists I have observed over my career, are doing an inadequate job of close guarding. I’ve seen it too many times in my 23 years as a physical therapist.

Here is one example of many that I have personally observed. In a rehab setting, a physical therapist colleague of mine does stair training with the parallel bars and I noticed she stands several feet away from the patient. She instructs the patient to rely on the parallel bars only when needed, trying to attempt the step without using her arms for support.

On this day the patient starts to fall but catches herself with her own arms; the therapist was slow to intervene but the patient was uninjured as she caught herself. The following Monday I hear that this patient fell during therapy over the weekend – while attempting stairs. The same therapist with (in my professional opinion) inadequate close guard habits was on duty over the weekend. Fortunately, in this case, the patient was only bruised; nothing broken no lawsuits no lasting problems. But it could have been much worse.

I know of another example where a patient’s femur was broken because of a therapist who was not close guarding.

Don’t let this happen to you or in your practice.

Think about your practice and your strategy for close guarding patients. Go over your practice policy and procedures manual. How good are you at close guarding to prevent falls? A patient doing stair training balance exercises or unsteady gait training, needs their therapist right by their side, with the therapist’s hands an inch or two away, and with the gait belt on.

As a vestibular and balance therapist for more than 10 years I’ve seen patients lose their balance multiple times during any given hour; don’t let that be one of your patients. Examine your staff and therapists’ practices. If they are not touching the person or a maximum of 2 inches from them, they will not likely able to prevent a fall. And someone will be injured.

We all can do better.