Balance and Fall Prevention After Cancer Treatment

Staying upright depends on three streams of information: what your eyes see, what your inner ear senses, and what your feet and joints feel. A fourth thing, muscle, has to act on all of it fast enough to matter.

Cancer treatment can damage every one of those.

• Feeling. Chemotherapy-related neuropathy dulls sensation in the feet. NCI reported on a study of over 500 survivors about six years after chemotherapy, in which those with lasting neuropathy were twice as likely to fall.
• Blood pressure. NCI notes that damage to autonomic nerves can cause dizziness from low blood pressure. Anemia adds lightheadedness, dizziness, and fainting to the list.
• Vision. NCI lists cataracts as a possible late effect of some chemotherapy, hormone therapy, immunotherapy, and steroids.
• Muscle. Weeks of treatment, low activity, and steroid use all cost leg strength.
• Medicines. Opioids, anti-nausea drugs, sleep aids, and blood pressure medicines all affect steadiness.

That is why the fix is never one thing. Falls have several causes at once, so prevention works by removing several risks at once.

CDC's STEADI program screens older adults with three questions. Answering yes to any one puts a person in the at-risk group:

• Do you feel unsteady when standing or walking?
• Do you worry about falling?
• Have you fallen in the past year?

STEADI was built for older adults. The risk factors it targets, though, are exactly the ones cancer treatment creates, so the questions are worth answering at any age after treatment. Falls are common and serious: CDC reports that 1 in 4 older adults falls each year, about 3 million are treated for fall injuries, and roughly 41,000 die from falls annually.

If you answered yes to any of the three, tell your oncology team and your primary care doctor. Do not wait for the fall.

CDC uses simple functional tests. Two are easy to try at home with someone spotting you.

Timed Up and Go. Sit in a standard chair with arms. Place a marker on the floor 10 feet away. On "go," stand, walk to the line at your normal pace, turn, walk back, and sit down. Time it. CDC's cut point: an older adult who takes 12 seconds or more is at risk for falling.

Four-stage balance test. Hold each position for 10 seconds without moving your feet or grabbing support, progressing only if you succeed: feet side by side; the instep of one foot touching the big toe of the other; one foot fully in front of the other, heel to toe; then standing on one foot. CDC's marker: someone who cannot hold that heel-to-toe tandem stand for at least 10 seconds is at increased risk of falling.

Do these next to a counter, with a person present. Write down the results and bring them to your appointment. A number is harder to dismiss than "I feel a bit wobbly."

CDC's algorithm pairs each risk factor with a specific action. This is the part most fall-prevention advice leaves out.

• Weak legs or poor balance. Referral to physical therapy, or an evidence-based exercise program such as tai chi. The federal Physical Activity Guidelines back this: older adults should do multicomponent activity that includes balance training, alongside aerobic and muscle-strengthening work.
• Fall-risk medicines. A medication review that stops, switches, or reduces the dose. Bring every bottle, including over-the-counter and sleep aids.
• Home hazards. An occupational therapy evaluation of the home. This is a covered referral in many plans and people rarely think to ask for it.
• Blood pressure dropping on standing. CDC lists medication adjustment, hydration, compression stockings, and education on how to move.
• Vision problems. Referral to ophthalmology, or a medication review.
• Footwear. Education on fit and traction, or a referral to a podiatrist.
• Low vitamin D. Daily supplementation.

Two of these deserve emphasis for survivors. Balance training is a trainable skill, and NCI's report on neuropathy and falls specifically recommended rehabilitation that improves balance during movement and corrects gait, because neuropathy changes how people move rather than making muscles weak. And a medication review is the fastest single win available, because it costs one appointment.

NCI's advice for people with neuropathy doubles as a home safety list:

• Move rugs out of your walking path so you cannot trip on them.
• Put rails on walls and in the bathroom.
• Use bathmats in the tub and shower.
• Wear sturdy shoes with soft soles, indoors as well as out.
• Check your feet daily, since a cut or blister you cannot feel can become an infection.
• Use potholders in the kitchen, and have someone check bath water temperature, because numb skin misjudges heat.

Add light. Put a lamp within reach of the bed, a nightlight on the route to the bathroom, and a switch at both ends of any staircase. Most night falls are lighting problems wearing a balance costume.

Balance work reduces how often you fall. Bone health decides what happens when you do.

NCI notes that chemotherapy, steroids, hormone therapy, and radiation can all thin bone, and that with radiation the loss happens in the treated area. That is worth raising directly, since a survivor with thin bones and poor balance is a different risk than either problem alone.

Ask whether you should have a bone density scan, whether your calcium and vitamin D intake are adequate, and whether any treatment for bone loss applies to you.

• Do I have neuropathy, and should I be referred for balance and gait rehabilitation?
• Does my blood pressure drop when I stand? Can you check it lying and standing?
• Which of my medicines raise fall risk, and can any be stopped, switched, or reduced?
• Should I have a bone density scan?
• Can you refer me to physical therapy, and to occupational therapy for a home assessment?
• When did I last have my eyes checked?
• Should I be taking vitamin D?
• Is a tai chi or supervised balance program available near me?

Call 911 straight away for sudden trouble walking, new double vision, slurred speech, or a face that droops. Those can be signs of a stroke, and treatment is time-critical. Go to an emergency department after a fall if you hit your head, if you take a blood thinner, if you cannot bear weight, or if there is a new deformity, severe pain, or a bone that may be broken. Sudden weakness or numbness in both legs, or new trouble controlling your bladder or bowels, also needs emergency assessment rather than a call.

Call your care team the same day for:

• Any fall, even without injury. It changes your risk category and should be in your record.
• Fainting, or near-fainting on standing.
• Weakness or numbness in one leg that is new or getting worse over days.

See Neuropathy During Cancer Treatment and Exercise With Neuropathy: What to Ask for the nerve side, and Bone Loss After Hormone Therapy for bone health. Also useful: Exercise After Cancer Treatment, Strength Training During Cancer Treatment, and What to Expect at a Survivorship Visit.

• STEADI Algorithm for Fall Risk Screening, Assessment, and Intervention (PDF), Centers for Disease Control and Prevention
• STEADI Clinical Resources, Centers for Disease Control and Prevention
• STEADI Patient and Caregiver Resources, Centers for Disease Control and Prevention
• Timed Up and Go (TUG) Assessment (PDF), Centers for Disease Control and Prevention
• 4-Stage Balance Test (PDF), Centers for Disease Control and Prevention
• Nerve Problems (Peripheral Neuropathy) and Cancer Treatment, National Cancer Institute
• Persistent Neuropathy Increases Fall Risk among Cancer Survivors, National Cancer Institute
• Anemia and Cancer Treatment, National Cancer Institute
• Late Effects of Cancer Treatment, National Cancer Institute
• Physical Activity Guidelines for Americans, 2nd edition (PDF), U.S. Department of Health and Human Services