April 1, 2014
“A patient steps on a device that assesses her balance as Jennifer Millar (left) and Yuri Agrawal stand guard.”
By the time Tara Norwich* arrived at Johns Hopkins Hospital’s Falls Prevention Clinic, she was terrified to walk a single step. The 48-year-old Tampa, Fla., resident had been referred to Johns Hopkins neurologist Jason Rosenberg after a car accident left her with a mild traumatic brain injury and severe migraines. Most alarming, however, were Norwich’s repeated falls—so severe that she endured orthopedic injuries, leading to a hip and knee replacement.
Norwich is among the 18 to 20 people per month who visit the clinic for evaluation and guidance. Most are 65 and older, says physiatrist Erik Hoyer, one of the clinic’s medical directors. People in that age group are almost three times more likely to fall every year, he says. And those who fall are two to three times more likely to fall again.
The clinic sees patients of all ages who tend to fall because of preexisting problems or an unidentified medical cause. In 30 percent of cases, vertigo is the culprit and can be treated effectively, says clinic medical director Yuri Agrawal, an otolaryngologist and vestibular specialist. Many other factors could be at play, however, she says. “Understanding what helps a person stay upright and maintain balance and locomotion is complicated. The only way to treat this multifactorial problem is with a multidisciplinary solution.”
What sets the clinic apart from the handful of others around the country, she explains, is thorough assessment across disciplines and immediate intervention. Using a falls rating scale based on severity and a questionnaire Agrawal and her colleagues developed, a seasoned PT and OT assess motor, vestibular, ocular, neurological or musculoskeletal problems. The workup includes video recordings of patients walking, as well as ocular movements. Cases are presented to the multidisciplinary board, which includes an ophthalmologist, geriatrician, vestibular specialist, otolaryngologist, physiatrist, neurologist, orthopedist, psychiatrist, PT and OT. Together they develop a customized plan for each patient.
“People age 65 or older are almost three times more likely to fall every year, says Erik Hoyer.”
This approach appeals to patients, says physical therapist Jennifer Millar, because they needn’t see multiple specialists at a high cost. It also means that treatment can begin sooner rather than later. She and therapist Anne Spar craft exercise programs that improve balance, strength, flexibility and endurance. They teach patients how to modify their routines to maintain or improve independence. The clinic’s OT, Brittany VanZanten, also recommends ways to reduce risks for falls at home, like eliminating area rugs.
Staff members also reinforce family education and safe mobility. Patients with Parkinson’s disease, for example, says Millar, don’t do well getting out of a chair while someone is talking to them, so patients are encouraged to focus on one thing at a time, while the families are advised not to distract them. Adds Agrawal, “We ask patients, ‘What are you afraid of? What changes in your life have you made?’”
In Norwich’s case, the team found that visual impairments and poor depth perception contributed to her falls. Before sending her home, the neurologist referred her to a developmental optometrist to improve her ocular motor function. Now she writes that she can better perceive doorways and feels more confident. “She’s extremely grateful,” says Millar, and is mobile once more—without the paralyzing fear of falling.
*Not her real name.