Multidisciplinary working in the Falls clinic at St Mary’s hospital.

You have all heard about my Multidisciplinary working in the Foot & Ankle Orthopaedic clinic at St Mary’s Hospital. Today I want to share what my Wednesday afternoon looks like in the Falls clinic. Again, this is another multidisciplinary clinic.

I am sure you are sensing a pattern here – I love working with other disciplines – I find it highly beneficial not only to me, but for my patients. In fact I tend to thrive in such an environments. The main purpose of my clinical practice, is that I would like to provide the best evidence based care for my patients. That is the most important factor when I work with any patient whether in the NHS or private sectors. I would like to able to provide the best care possible in my capability. This also means that I am not afraid to say ‘I am not sure what is going on’ but I will go above and behind my means till I get the correct advice for them.

Before I show you what my Falls Multidisciplinary clinic looks like, I want to discuss falls and why they cause such an impact in patients’ life.

Definition of Fall?

A fall is defined as an event which results in a person coming to rest inadvertently on the ground or floor or other lower level. (https://www.who.int/news-room/fact-sheets/detail/falls).

Important Facts about Falls

·      Each year, millions of older people—those 65 and older—fall. 

·      Approximately 50-70% of falls in older people occur when walking

·      In fact, more than one out of four older people falls each year, but less than half inform their GPs.

·      Falling once doubles your chances of falling again.

·      One out of five falls causes a serious injury such as broken bones or a head injury, leading to hospitalisation due to head injury or a hip fracture. (https://www.who.int/news-room/fact-sheets/detail/falls).

·      Falls among the over-65s cost the NHS and social care in the UK an estimated £5.6 million each day. Falls are serious and can be a costly affair.

What are the risk factors for falls?

There are vast number of factors that can contribute to an increased risk of falling - factors that literally run from head to toe. 

For example:

·       poor or decreased eyesight, 

·       dizziness which could be related to inner ear problems or 

·       heart problems such as postural drop in blood pressure, 

·       pain that limits mobility, such as back, hips, knees or ankle or foot pain, 

·       weakness in leg muscles, 

·       poor footwear or long nails – unable to be cut as unable to reach your feet.

Falls amongst older people can be devastating and life changing events but they can be prevented with a little foresight.  Some of these factors above can be prevented, corrected or mitigated, while others cannot. 

Each and every one of us is eventually going to go through the ageing process – this is a fact of life!  However, it is extremely essential to maintain a healthy musculoskeletal system throughtout all ages.  Without this, movement slows down, the body becomes unstable, and eventually ceases as all joints become stiff and excessive atrophy occurs where the muscles waste away. 

Or to put it simply – use it, or loose it!

Leading a sedentary life when you become older causes more harm than good and this is a major health problem in our aging population.

Without the ability to physically move about there is no health, regardless of one’s age. 
This not only has implications for falling, but on our patients' independence and overall quality of life.

By maintaining muscle mass, strength, and coordination, especially in their lower extremities and core region, we as in the General public can reduce their fall risk in support of a healthier aging process well into their oldest years.

What is so different about the Falls clinic in St Mary’s Hospital?

It is a unique service.

It is ONE STOP SHOP because all the medical disciplines sit in one room with the patient and the patient is examined from head to toe. The appointment can last between 60-75mins

Who are these various medical Professionals that sit in with the patients?

How does the clinic begin?

It begins with Multidisciplinary team meeting – this gives an idea of back ground information on each patient such as previous falls, medical history and if they have attended the falls prevention physiotherapy classes or known to the local podiatry clinic.

The clinic is very much Patient Centred.

The Consultant, the Registrars, the physiotherapist and podiatrist move rooms but never patients.

As soon as the patient arrives, they are initially assessed by the Osteoporosis nurse who measures their height, weight, calculates their Body Mass Index (BMI), and measures their lying and (standing blood pressure at 1 minute and 3 minutes) to see if they have postural drop. She also enquires about their bone health and discusses their lifestyle and issues with a leaflet about increasing salt intake (yes you read this correctly) as well as water intake but reducing caffeine intake.

The patient is then brought in to the room with the Consultant/Registrar and the physiotherapist and podiatrist(myself).  It is overwhelming for the patient but this soon fades away after being introduced and the need for all of us in one room.  We all sit together so the patient does not have repeat their medical history to each one of us. 

The Consultant/Registrar enquires about their medical history, their falls history, their eyesight. They also perform an assessment and listen to their heart. 

The physiotherapist performs a balance test consisting of 14 tasks.  This starts off easy, with tasks such as getting up from the chair unaided and then becomes a little more challenging, like standing on one leg.

My Role:

As a podiatrist, I have the ability to identify an ‘at risk patient’ from experiencing a potentially life-changing fall and can act to prevent them, plus I can also provide a wide range of foot care treatments.

Who do I help? Well anyone who has history of falls and want to prevent further falls and those who have an unsteady gait.

As a podiatrist the focus is on the lower limb and this can include:

·       Footwear – including house shoes and slippers.

·       Nail problems, hard skin and wounds.

·       Gait assessment – how they walking and moving.

·       Sensation and blood flow assessment.

As you can imagine, seeing lots of specialists so quickly means that we cannot manage everything during that first visit, and our focus may well be on the “quick wins” to provide the most good to the patient, and the findings from my assessment and that of the team help to decide what this direction should be.

One thing is really important to note here – the patient is always involved and we work together to find a solution that helps them and reduces the risk of falls.

This is always discussed as a small group meeting at the end of the appointment.

Why do I love this clinic? 

It’s a great example of different disciplines all working together for a common goal.  And it makes me and my profession feel valued.

But ultimately I get to make a difference.

I can give you many examples of how patients have been helped as part of the falls clinic, but I want to tell you a story a bit closer to home.

This time it involves my mama. 

Now my mother has only really been in hospital to deliver her babies and has managed to escape hospital stays or surgeries, unlike my father who seemed to be like a cat with nine lives. There has been a history of cardiac problems in her side of the family and although she was coping well without any major problems, it did catch up with her in the last couple of years. 

It all started with her feeling dizzy & unsteady when she got from sitting or lying, her blood pressure was fluctuating and she had had a few near misses or had had a fall. She had also experienced a few blackouts and would sometimes get severe pain in her jaw – a symptom of angina. 

As it turned out she had been experiencing a series of mini heart attacks in Kenya, and due to my work commitments, I was unable to be with her, but my siblings assisted her. 

In July 2018, she had a heart attack here in London.  This was rather unfortunate for her but fortunate for me, as I was with her throughout the process and able to question her the doctor myself to no end, instead of speaking through my family. She was able to see her cardiologist who carried out arthrogram and she had stents put in. 

The cardiologist was very clear that she was frail and had lost a lot of muscle mass due to lack of movement through her symptoms. She really needed to keep mobile and as active as possible. Although she started off well, she did not pursue it for very long.

About 8 months down the line, I went to visit her in Kenya. My brother picked me up from the airport and even before we had left the main road, he suggested that I need to get our mother some rehabilitation in the form of physiotherapy.  Apparently, my siblings had tried very hard to arrange this, but she was adamant that she was perfectly fine and needed no one – sound familiar! 

I know many of my readers do not know my mum but she has a razor sharp memory (and tongue), she has a keen eye on all things fine and beautiful – mainly clothes and jewellery and she is one excellent cook who can whip one a meal with the most basic of ingredients but once she has made up her mind, you cannot persuade her to change. 

So this was no easy task– I was already panicking how I would do this in my 2 week break. And this was before I had actually arrived at the house or seen her.

This is how I went about it. 

Lucky for me, she had already started using a walking aid a few years prior. And although, she was not socially keen on the cane as it is often associated with aging, weakness, dependency and I guess, her fear of losing her independence plus her pride!  But, she soon discovered that it is an amazing deterrent when walking in large crowds and she could command respect if she waved it around.  She also noticed that it helped improve her mobility, regain her independence and increase her confidence when walking. I had made sure she had been trained in keeping it at the correct height to ensure she did not need to stand funny in order to reach it. I also made sure that she kept as close as possible to her so that she won’t fall from trying to catch up with the aid.

Although she was using the cane during the day time, I noticed at night time, when she got up to use the bathroom, she was furniture walking and mainly in the dark. 

I would sleep in her room and I would have my heart in mouth each night when she got up. I would watch her with one eye open, pretending to be asleep – as I have mentioned she is extremely sharp. If I did call out to her and ask her if she was ok, I would normally get my head bitten off. 

If she said in the bathroom, longer than I anticipated and called out, it would be the same reaction from her – leave her in peace to carry out her business! 

But I had these terrible visions of her falling in the bathroom and nobody would hear her till the morning.  So, after a couple of nights, I plucked up the courage (after a few long prayers with the Lord so that I would not be on the rough end of her tongue), and expressed what I had noticed. 

I told her I was worried about her, especially if she fell and could not get back up.  Now I did mention that she is an extremely clever lady and had thought of this eventuality, she told me that her bathroom fell on to the garden side and she could call out to the watchman and he would go and call my brother but she understood my fear. 

After a lengthy discussion over the next few days and me planting a seed in her which I had to watch it grow, she agreed to have a Zimmer frame mainly for her night time trips.  I also expressed that such aids need to be shown how to be used appropriately and the need for a physiotherapy to come in for one session would be highly advisable and secondly, should she fall, it is important to know how to get up from the floor, again something which the physio can address. 

She agreed to having her for a session, which was amazing and I nearly let out a cry of joy that I had the power of persuasion to change my dear mother’s mind!  This was no mean feat! I immediately texted the rest of the family – that she is on board!  

She then told me that she knew what I was up too!

I arranged for the physiotherapist to attend who spoke the same language as her. They got along famously. The physiotherapist was very calm and gentle and managed to persuade her that one session alone would not help. I did warn the physiotherapist my mother would chase her out as soon as I left the country. To my extreme amazement, she got along very well with the physiotherapist and saw her three times a week. My mother also told me that she loved talking to the physio but if she spent too much time chatting, this was time she wasted away from the exercise so she kept it to a minimum!

I revisited my mother in Nov 2019 and she had maintained her rehab sessions. She looked less frail. Still petite but had some light muscle bulk. She had good balance too. She was very proud of what she could do and wanted me to sit in with her. Once she finished her session, I told the physio and mum, I was proud of her bridge positioning on the bed that I would normally struggle with and physio agreed how she, herself found it so difficult too – my mother was very quick to point out that I could not do it as well as her “as I had rather a large stomach as I eat too much and the physio had not lost her weight from her pregnancy”. 

I am not sure of the physio’s reaction, but I had to laugh, my mother’s sharp tongue is back!

Falls can affect us all at some point during our lives.

Ask yourself these questions:

·       Is foot pain hindering your activity as you suffer from fear of falling?  

·       Have you fallen in the past?

·       Or do you know someone that is at risk of falling?

Maybe I can help?