Many of us start to experience our body slowing by middle age, with sore knees and aching backs taking their toll. But for some, the limitations on mobility come later: stooped posture, dizziness, and difficulty with walking on uneven surfaces.
Mobility — simply, the ability to move around in space — is strongly associated with long-term health and well-being. But issues with mobility can be complex and challenging to diagnose. And since about 20 percent of older adults who fall and fracture a hip die within a year, mobility issues can even be lethal, raising the stakes for patients.
“Walking speed is probably as good a predictor of mortality as any we have,” says Dr. Neil Alexander, professor of internal medicine and senior research professor in the Institute of Gerontology at the University of Michigan. He is also the founder and director of the university’s Mobility Enhancement Clinic. “It’s a common denominator for all these systems.”
Indeed, problems with walking can be tied to a range of issues in the body, such as osteoporosis, cognitive impairment, inner-ear imbalance, Parkinson’s disease, and spinal problems. But very few clinics in the country are devoted to studying and diagnosing mobility-related disorders.
The Mobility Enhancement Clinic grew out of Alexander’s research interests in body mechanics in older adults. Eventually, Alexander decided to translate his research interests into assessing and working with patients. (The clinic is part of the Mobility Research Center, which he also directs.) He secured space for the clinic and began seeing patients in partnership with a physical therapist.
That model was disrupted a few years ago when Medicare limited its reimbursement for physical therapy. Now, Alexander sees patients alone and refers to his former partner and to other specialists.
“The research drives the clinic and clinical experience drives the research,” he says. “I’ve made some decisions about what I think are critical indicator tests, and I determine a diagnosis based on that. The history and physical gives me most of what I need. Sometimes I order imaging or brain scans to see white matter changes; there’s a growing notion that those changes affect thinking and walking.
“Determining the cause of falls is a dicey situation,” he adds. “By the time people come to me, they’ve already been through a certain amount of screening and agree there’s something going on.”
Dennis Curtis, 74, of National City in northern Michigan, saw Alexander last year for help. He’s had a walking problem for 10 years.
“I get tired and start weaving around,” Curtis says. “When I get in a crowded area, I have trouble and need to hold on. I saw a couple of doctors and never got any good results, and it was getting worse.”
His daughter suggested he try Alexander’s clinic. Curtis says they spent two hours together in his first appointment, with Alexander having him try a number of routines to test his strength and agility. Curtis was also having a hard time lifting his arms, and was unable to hang his tools on their usual hooks at home. Alexander ordered some tests, which picked up issues with Curtis’ neck.
Alexander called him, Curtis says, and advised him to go to the emergency room after reviewing the results of his MRI. Surgery followed, with operations for his shoulder and lower back expected later this year to correct issues stemming from decades-old accidents.
“I can get my arms above my head now,” Curtis says. “All of a sudden, I’m able to reach up and get things, put all my things back on the shelf. I’m able to use my arms.”
Sometimes, a symptom is hard to get a bead on.
“People will come in and say they’re dizzy,” Alexander says. “It’s hard to figure out what they really mean. Vertigo suggests an inner-ear problem versus lightheadedness, which is connected to other problems.”
Barbara Bentley, 77, went to see Alexander after passing out and falling down the stairs in her Southgate home.
“I didn’t break a bone, but I cracked my head on the basement floor,” Bentley says. “From that time on, I was having dizzy spells. Then last July, I was pushing my chair into my kitchen table, I turned, slipped, and fell down and cracked my head on the table.”
Bentley visited a dozen doctors in her quest to determine the cause of her dizziness. Her son came in from Arizona and helped her make appointments with physicians at U-M, one of which referred her to Alexander. He determined she had benign paroxysmal positional vertigo, a condition caused by crystals in the inner ear getting knocked loose and disrupting the proper flow of fluid in the inner ear canal. A series of repositioning maneuvers can reset the crystals into their proper position.
“He did his technique and it changed my whole life,” Bentley says. “I haven’t had a dizzy spell since and that was a year ago.”
Often, Alexander’s work is less about diagnostic sleuthing and more about helping patients adopt necessary lifestyle changes.
“The treatment is [often] not a pill but some sort of physical treatment, or even more importantly, behavioral changes,” he says. “You have to use your cane, you have to turn on the light, you have to wear these shoes.”
There is no longer any question that physical interventions and exercise can help reduce the risk for fall-related injuries, he says. “But, likely, behavioral interventions are just as important — how you think and how you act.”
Ernest Fontheim, 94, sought Alexander’s help a couple of years ago. Arthritic knees were making walking increasingly painful, but a heart condition, combined with his age, ruled out knee replacement as an option.
“He examined me and went into all kinds of options for my legs and so on to analyze what interferes with my mobility, and he gave me very good advice on how to overcome some of the difficulties,” says Fontheim, a retired U-M engineering research scientist. Alexander referred him to physical therapy and gave him exercises to do on his own. Afterward, he felt “more invigorated.”
“People come to me not just for a diagnosis; they want to get better,” Alexander says. “The intervention has to be thoughtful and subtle. You have to dig deeper. I try to give them something to do to make them, if not better, to slow the decline.
“We’re all declining,” he adds. “But you can go slower.”
Avoiding Falls
Most people with mobility issues are well aware they exist. But even if you think you’re getting about just fine, if you’re older than 60 and have fallen two times or more in the last six months, you may have a mobility issue.
Here are some tips for avoiding falls.
Take arthritis seriously.
“People blow off arthritis,” Dr. Neil Alexander says. “But if there’s pain, deformity, weakness in any one of these sites, it affects walking and, more importantly, affects their ability to react in a fall situation. Even in your shoulders — you need your arms to walk.”
Get your ears checked.
Inner-ear damage affects balance, as does impaired hearing. Fewer auditory cues from the environment make it harder to orient properly in space.
Get your eyes checked, too.
“Vision is probably the most critical piece to maintaining your balance,” Alexander says. “A lot of people are walking around with underdiagnosed or mild cataracts. There’s very strong literature that suggests if you fix just one cataract, you’ll decrease your fall risk.”
Consider the state of your cognition.
Failing attention or incipient dementia are linked with falls. Neurological issues generally can manifest subtly in the body, especially in their early stages.
Mind your blood pressure.
Low blood pressure can cause head rushes upon sitting or standing, which can result in falls.
Skip the multitasking.
Avoid carrying loads of laundry or other items that can impede your vision while walking.
Make peace with assistance.
People often avoid canes and walkers because they view them as stigmatizing. But using a cane beats breaking a hip. If need be (or preferred), hold onto a wall, furniture, or other people, and keep a fold-up walking stick on hand for uneven surfaces.
Consider tai chi.
The Chinese system of movements builds strength, balance, and flexibility. “Tai chi is thought to be as good an intervention as we have,” Alexander says. “I’m not saying you shouldn’t go to a gym or exercise class. But make sure there’s a balance element. If you need a chair to hold onto, that’s fine.”
Evaluate your environment.
Poor lighting, uneven, slippery surfaces, and trip hazards all pose risks to older adults. Numerous home safety checklists are available online, including one from the Centers for Disease Control and Prevention.
Move mindfully.
You can improve your home’s safety, but removing all risks is impossible. Preventing falls requires mindful movement. Turn on the lights, slow down, and strategize for stairs and challenging surfaces.
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