Wednesday, April 11, 2007

Balancing Act

I returned to work yesterday after having more than a week off and kept busy updating myself on the new admissions and changes in my regular caseload. I have said before that I really enjoy my job and that has not changed. Long walks and nature observation are stress relieving pastimes, but working with people is most rewarding for me.

I walked in a room to introduce myself to a new patient and recognized her right away from her admission a couple of years ago. She had a past history of a stroke that had left her weak on one side. When I last saw her, she was using a wheeled walker or cane to walk and used a wheelchair for distances. She had gone on a bus tour, and when the group stopped for lunch, she fell while walking into the restaurant and broke her hip. She required surgery and will be in hospital for an extended period of time.

This is a very nice lady, without cognitive impairment. I asked her if she had been using her cane or walker when she fell. Well, the answer was a sheepish, "No". I stopped myself from lecturing because it was obvious she knew she had taken a costly risk.

A big part of my job is fall prevention education. We do a number of tests to determine the risk of falling and the need for an adaptive aid. Many things can impair balance, including strokes, degenerative neurological diseases and peripheral neuropathies, most often caused by diabetes.
But many people develop weakness and balance problems because of inactivity and disuse. When is the last time you saw an adult playing hopscotch, or walking in tandem steps on a curb stone? Children often perform high balance activities as part of play.

One of the tests we do has 14 components to score a person's fall risk. We ask the patient to stand on one foot for 5 seconds, repeating with each leg. People who cannot do this tend to shuffle or walk quickly and need to use a gait aid. It should be easy to maintain a one legged stance for 20 to 30 seconds and this can improve with practice.

Another position we ask a person to take is a tandem stance, one foot in front of the other. Most of my patients are unable to do these two activities.

Our universal government health plan covers 75% to 100% of the cost of a new rollator walker and I do many prescriptions for people who need one. The problem is that people will not always use them. Pride and independence seem to be present in two year olds and eighty year olds. I feel I have done my best work when I prevent someone from having a bad fall rather than getting them back on their feet after a broken hip. Doing simple balance exercises, engaging in regular activity, and using suitable adaptive aids can help maintain independence for many years.

My new patient will always need a walker, if she is able to walk independently again. If she could only go back in time to that bus and disembark with her cane!


  1. Pride and independence seem to be present in two year olds and eighty year olds.

    Oh, how true this is Ruth! The sad thing is that an event like a hip fracture can end quality of life as they've known it for an 80 year old. That fact is one they don't entertain when feeling "independent" and cheeky enough to stroll unassisted.

  2. When it safe and clear around here, I'll flip the shoes off and see how well I do with the balancing tests. Falls scare me. The last one I had was nearly two years ago when I fell off the back deck (long story) and broke an ankle in two places which resulted in surgery. I still have the hardware. Since then, I'm constantly "watching my step".

  3. OK. I'm about to stand up and see if I can balance for anything over 5 seconds. Does that 20 to 30 seconds apply to all ages? This is scary.

    Gosh! I hadn't heard Mary's story before. More 'scary'. But I know she's up and moving. Yea! Mary!

  4. And here I thought the only reason one would stand on one leg was as a sobriety test!
    Kidding aside, I have a weak knee and practice standing one-legged on that leg, just to force the knee to gain strength.

  5. Anonymous4:12 pm GMT-4

    I'm going to show this to my former mother-in-law next time she visits. She is 85, can barely walk due to bad knees, yet refuses to use a cane. I am terrified she is going to fall before she gets surgical help for her knees. Maybe reading your post will help convince her...

  6. Ruth- My 89 year old Mom will only use her walker for longer distances and refuses to use it around in her apartment. She is convinced that using the walker over the last years has made her more dependent on it, and that her repeted falls are due to that dependence. How do I argue with that kind of logic?

    Another example- a few years before my Dad passed away we had just come from a doctor's appointment where the MD had told Dad that he neede to be using his walker "all of the time". Dad asked me how long I thought he'd have to use the walker, and I told him he would need it always (Parkinson's tremors). My mother was infuriated with me saying that my words had taken hope from my father. No amount of reasoning would sway her thinking.

  7. -I was pleased to find out that I can stand on one foot for the 30 seconds-didn't think I could.
    I've noticed that some people seem to use a walker much more efficiently than others.

  8. Jayne- Risk taking comes in many forms. People think it could never happen to them, yet hip fractures are the number one diagnosis on my caseload.

    Mary- I am sure you can perform those tests and if you keep to the trails with your camera, you will stay in great shape. Studies show that most women's balance performance drops sharply after age 50. It doesn't have to be that way.

    Cathy- My daughters can stand on one leg longer than I can, so age likely does affect performance. The 5 second minimum we expect is really low level. Better to maintain a 10-20 second performance even in the geriatric population.

    KGMom- Yes, our test is much like a sobriety test! Keep working those knee muscles.

    LauraO- Knee replacement surgery doesn't restore balance in some people. In fact, people are more likely to fall after knee replacements as the artificial knee surfaces have no nerve endings and people have less position sense in their legs. I hope she doesn't have a fall!

    Lynne- You describe exactly the thinking and arguments I hear every day. People presume they will get stronger if they don't depend on a walker. I tell them that if they need a grocery cart to get around the supermarket, they need a walker too. I sometime liken it to a piece of exercise equipment. People will walk farther if they feel safe. Would they go without glasses to see if their eyes would get stronger? My arguments don't always work though.

  9. Larry- Make sure you can do that one leg stance for the rest of your life.
    I don't know if you are 2 score years or 2 score and 10! ;-)
    I tell my more able bodied patients to stand on one leg and then the other when they brush their teeth, so they remember to practice every day.

  10. Thanks for the good advice. I like the teeth brushing exercise. I can remember that! :0)

  11. I'm with Cathy on that one. I'll do it.

    I did well on my test today but I faltered a little bit on my hardware filled left.

    I was happy with it!

    Thanks, Ruth!


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