Tuesday, June 17, 2008

Fall prevention

One of the most important things I can do as a physician is prevent falls. I've been thinking about this quite a bit lately for a few reasons. One, someone very close to me has had a series of nasty falls. Second, as I say goodbye to some of the patients I've met in Arkansas, I've been able to see that we've made some successful interventions in preventing falls.

The first point I want to make is that falls are a big deal. For many patients, as they get older, the biggest barrier to them maintaining independence is making sure that they don't fall. When you are younger, the consequences of a fall are much less, since you can catch yourself if you stumble, and if you do actually hit the ground, you may only have a contusion. As you get older, you may deal with more catastrophic consequences, like a broken hip or a subdural hematoma (head bleed).

A useful analogy is automobile safety. The traditional American perspective on car safety is to buy the biggest, baddest car on the road (e.g., a Hummer), so that if you get into an accident, your chance of getting hurt is minimized. That is one way at looking at things, I suppose. But who says that accidents are inevitable? Another approach to safety is buy the most nimble and maneuverable car available, which can help you avoid an accident in the first place.

The same is true of falls. Much of the focus in preventing fractures has been working under the assumption that falls are inevitable, and working on damage control when the falls happen. So, for example, bisphosphonates (like Fosomax) are popular drugs that work to prevent bone breakdown, so if you fall your bones will be thicker and less likely to fracture. Additionally, many patients come in to see me because of the consequences of their falls (broken bones, dislocated shoulders, split lips, back pain, etc). While I can help them with some of these consequences, I wish I could have seen them earlier- before the fall ever happened.

Back to the car analogy- rather than focusing on airbags and crumple zones, you could focus on accident prevention. And the same is true of falls- we do not have to assume that falls are inevitable, but can make interventions ahead of time to make falls less likely.

In order to make these interventions, we have to think about what causes falls in the first place. While there are some extreme circumstances that can cause a fall- dodging a car, getting hit by a falling tree, etc- most falls are flukes. Most of the time, when people fall, they stumble over something minor (e.g., the edge of a carpet, a curb, uneven grass in a field, a crack in the sidewalk, a dog toy on the floor), and because they have a poor base of support, they stumble and eventually fall.

So, what can you do to prevent falls? Well, let's look back at the prior paragraph, becuase there are a few key elements there:

1. Minimize the little things- while there are always things that could potentially trip someone, there are many things that are easy to fix. For example, making sure that you don't have loose items on the floor that you could trip on (child's toys, dog or cat toys). Make sure that you don't have loose rugs, or if you do, that they are taped down at the edge.

2. Awareness of your surroundings- as we age, we tend to become less aware of our surroundings. Part of this is the wisdom of aging- you become so accustomed to your surroundings, that you fail to notice subtle changes (e.g., a new crack in the sidewalk). Additionally, as we age, we tend to have less feedback from our senses- our vision is not as acute, we have less feeling in our feet and less sense of where our joints move in space, we can't hear our grandchildren or dogs. For all of these reasons, we may become less aware of potential stumbling blocks. This is trainable, however- you can become more aware of your surroundings.

3. Improving our base of support- this is the key. Have you ever tried to balance a folding chair on just 2 legs? It's nearly impossible- 2 points of contact is an inherently unstable base. How about balancing a pen on one end? One point of contact is even less stable. Well, when you walk, you either have 1 or 2 points of contact. This is inherently unstable.
So, why don't we fall all the time then? Well, actually, we do. One way of viewing walking is that it is a series of controlled falls, where one leg is perpetually catching the other one from falling. As adults, we have sufficiently trained ourselves to coordinate this recovery process, but try watching a 7 month old walking. They haven't yet developed the recovery process, so instead of a series of controlled falls, they have uncontrolled falls (albeit, they are adorable controlled falls on to their cute little tushies).
As we age, our controlled falls become less controlled, and sometimes we stumble. Again, this is trainable- we can learn how to contol our base of support to minimize the risk of uncontrolled falls.

So, how should we go about this training? There are multiple approaches, but my 2 preferences are physical therapy and Tai Chi. I will speak about PT briefly, and Tai Chi at more length.

The key for physical therapy is to make sure the prescription is specifically for fall prevention, and that you work with a therapist who has specific skills in fall prevention. One essential factor as that at least a portion of the therapy has to be performed with the patient standing. While there are certainly benefits to seated strengthening exercises, the goal is to minimize falls while standing and walking, so the therapy must incorporate those positions. Similarly, modalties (things like heat, ultrasound, and electrical stimulation) can be helpful for providing transient relief of pain, they should not be the focus of a PT program designed to prevent falls. With those caveats, Physical Therapy is a wonderful tool that can help prevent falls.

Now, let's talk about Tai Chi. I am a big, big fan of Tai Chi, and have seen it make a huge difference in the lives of many of my patients. I will note that I have no financial interest in Tai Chi, so my enthusiasm (whether it is warranted or unwarranted) is purely based on my impression that it helps patients.

What is Tai Chi? Historically, it is a Chinese martial art, and like many martial arts, it not just (or even primarily) about fighting, but rather it is a philosophy and system about how to move the body.

Now, when I mention to some of my patients who have had recent falls that I would like them to take a martial art, there is some hesitency. This is understandable- they are mostly concerned with not tripping while they are bringing groceries, rather than how to take out a ninja with a nunchuck.

Tai Chi, however, is different than many other martial arts. One, it is slower. The movements are gentle, gliding movements, with significant focus on posture, breathing, and concentration. These are the very things that one needs to focus on to prevent falls. The movements are also geared toward always having a stable base of support. And I discussed above, that is the main key in preventing uncontrolled falls.

It is a real martial art, however- these very same gentle movements, if performed with a faster cadence, would actually be useful in combat. That is a bit of an aside, however, to our discussion- the main goal is fall prevention.

Does Tai Chi work? Probably. There are a decent number of studies that have showed reduction of falls in patients who participate in Tai Chi. None of these studies are perfect, but the confluence of the information in the studies make a decent argument that it probably helps.

My anecdotal experience is that it's one of the most useful interventions that I make with my patients. As I mentioned in my prior post, I am in the process of leaving my current job in Arkanas, so I've been saying my final goodbyes to some of my patients. One of the patients I said goodbye to today is an incredibly lovable 72 year old woman I've been seeing for the past 6 months. She's been raving about how much she has enjoyed her Tai Chi classes. Even more importantly, as I watched her walking out of the clinic, she had a very clear spring in her step.

That is one of the comments I hear most from patients who have started Tai Chi- they have a spring in their step. Another of my favorite patients- his wife has commented on how he looks younger now, and she thinks it's because of the way he looks when he walks. He has a more controlled gait- he always looks like he knows what he is doing. I can never be sure what made the dramatic change for these patients, but I attribute it to Tai Chi.

Fortunately, the availability of Tai Chi has grown tremendously. In the area where I currently practice, there is a wonderful senior center in North Little Rock called the Hayes Senior Center (http://www.northlr.org/departments/senior-citizens.asp). This is true of most urban and suburban areas- sometimes finding good Tai Chi classes is a bit more of a challenge in rural areas.

Anyway, to wrap up, here are my key points:
1. One of the most important steps one can take to maintain their independence is "Don't Fall"
2. Most falls are preventable
3. Normal walking is a series of controlled falls. The key is to make sure they are controlled, and the key to making sure your falls are controlled is to maintain a stable base of support
4. Tai Chi is a great way to train yourself to maintain a stable base of support

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