The backward faller — the pull test and the next fall
| Patient | 71M, moderate stage |
|---|---|
| ConditionIdiopathic Parkinson’s disease, H&Y III, with retropulsion and recurrent falls | |
| Severity | UPDRS-III 38 |
| Days since diagnosis | 2190 |
| Before the diagnosisIndependent. Widower, retired printer; cooked, shopped and gardened alone. | |
| Also on the chartOsteoarthritis, both knees — managed | |
| PrecautionsHigh fall risk, backward — supervision within arm’s reach for all standing work; Lives alone — daily check-in and an alarm pendant agreed before discharge | |
Test yourself
Which assessment should drive the fall plan?
The teaching
Recurrent backward falls in Parkinson’s are a reactive postural control failure, and the assessment and the treatment both have to be reactive: the pull test with standardized technique, the Mini-BESTest reactive domain, then compensatory stepping, perturbation work, backward walking and cueing. The falls literature is directional and consistent — past falls predict future falls — so four falls in a quarter puts him in the highest-risk band, and the home and the supervision plan are part of the prescription, not an appendix. What you do with it: test the pull, train the step, strip the rugs, arrange the daily check-in, and keep the wheelchair conversation for a stage that has actually arrived.
- A fall with head strike or loss of consciousness — medical review before the next session
- Any fall with a new neurological sign — this is not the disease talking; image and escalate
- Syncope or near-syncope in the story — lying and standing blood pressure, then cardiac referral
Read next
The full sequence
This page carries the case’s first decision. The full sequence — every decision, the examination by domain, and the debrief that grades you — is in the drill, and the library is included with membership.
Sources on this page: Munhoz RP et al. Evaluation of the pull test technique in assessing postural instability in Parkinson’s disease. Neurology. 2004. Duncan RP et al. Comparative utility of the BESTest, Mini-BESTest and Brief-BESTest for predicting falls in individuals with Parkinson disease. Phys Ther. 2013. Nonnekes J et al. J Parkinsons Dis. 2015 · Duncan RP et al. Comparative utility of the BESTest, Mini-BESTest and Brief-BESTest for predicting falls in individuals with Parkinson disease. Phys Ther. 2013. Pickering RM et al. A meta-analysis of six prospective studies of falling in Parkinson’s disease. Mov Disord. 2007. Osborne JA et al. Physical therapist management of Parkinson disease: a clinical practice guideline from the American Physical Therapy Association. Phys Ther. 2022. NICE. Parkinson’s disease in adults. NICE guideline NG71. 2017