Ground-level falls, NPH and how older adults get moving again

Knowing what the pitfalls are, knowing where are the common ways or the common reasons for people falling, and then trying to obviate that by teaching them perhaps how to lift up their feet, how to get their feet up above the curb, how to turn, how to balance. All these things, I think, are ways that therapists, therapists can help to educate this at-risk population. You're listening to the Restoring Human Movement podcast, where movement experts discuss the latest evidence-based practices to help you and your clients move with mastery. And now, your host, Dr. Sebastian Gonzales. Hey guys, this is Dr. Sebastian Gonzales, your host for the Restoring Human Movement podcast.

If this is your first time, thanks for joining the Movement Movement. This podcast is intended for healthcare providers as well as advanced patients to better understand what's going on outside of their little bubble, because I have a little bubble as well. That was a snippet from the interview that I'm doing today with Dr. Jeff Chen, or Jefferson Chen, who is a board-certified neurosurgeon at UCI, so University of Southern California, Irvine. He specializes in neurosurgery, neurocritical care, and neuro-oncology. So, I was introduced to him by a good friend who had nothing but great things to say about him.

And his patients love him. I interacted with him at a workshop or support group that he had for a condition called NPH, or normal pressure hydrocephalus. And his patients did love him, because I was waiting for my section to come up, and I talked to them, and they just had nothing but great things to say. I'm like, I've got to have this guy on, because I don't get a chance to talk to neurosurgeons or orthopedics that much. So, I thought, why not? Let's do it. My section in that presentation was just gait retraining. So, simple things that people can do to start introducing gait again. Because as we go through the topic today, his passion is, he wanted to talk about ground-level falls in elderly populations, or basically falls from not something high.

And then, kind of the aftermath that happens from there. And I was looking through some research before I came on, and there was one that actually was very surprising. I'll do some rough stats, and it said 12% died at admission when they went to the hospital. 51% were discharged to a skilled nursing facility. 33% went home without any assistance. Surprising. Because the readmittance rate within about a year was 44%. So, it was pretty high. So, I thought we'd cover a lot of those topics today. Now, before we get into the interview, let me do a little housekeeping. If you haven't reviewed this podcast or subscribed, please do.

It's the only way to really get good information out to the rest of the public, or to the rest of your peers, is to share it. And I'd love to say that you produce a great podcast with good audio and good guests and stuff like that. And it starts to fly, and it doesn't. It doesn't. Right now, we're venturing around about 1,000 downloads per episode, which I think is amazing because the opportunity to speak to 1,000 people and influence 1,000 people every single week is a great honor to me. But I've heard a podcast doing in the tens and hundreds of thousands. Let's do that. There's no reason to not get that going.

So, share it with one friend today. That's all I ask with that. Now, if this is your first time to the show as well, I typically do a small section to get, I think of it as the personal corner. So, it's more of a story that I'll tell about myself so you guys can get to know your host better. And then we'll get into the interview process. So, let's get into that part right now. So, I was recently watching Top Gun again, and I haven't seen it in years, and I realized that TVs have gotten so much better. And there's this one TV that one of my friends has that, like, you literally go over there and watch Animal Planet, or sorry, Planet Earth, and it's like you're looking out your window in the safari, and you can tell there's lines out there.

It looks better than real life. It's crazy. So, anyways, you start watching Top Gun, or we watch Top Gun. I never realized how many beads of sweat were on people at all times. And I think this one was filmed in, it was in California. I think it was down by, almost towards San Diego area in Del Mar or something like that. So, there is at least the houses down there where they kept playing Take My Breath Away about 13 times. I think it was 13 times throughout the whole movie. There was only two songs. I think it was Danger Zone and Take My Breath Away. But either way, though, the amount of sweat beads they put on these actors, like Tom Cruise, tons of sweat, you know.

Even the girls, tons of sweat. I kind of want to see what the background was of making the movie and how perfect they made those sweat droplets. And they knew probably about 20 years ahead of time that there was going to be these badass TVs that could really emphasize the sweat droplets. Like, I could barely even pay attention to the movie. There's so much sweat going on there. Anyways, if you haven't seen Top Gun in a while, that's a good part to pay attention to. So many sweat droplets, and you can figure, if you can count, I doubt you get it on two hands, how many times they play a section of Take My Breath Away.

All right, now on to the content. Okay, everyone. Welcome on, Dr. Jefferson Chen. Do you want to be Jeff or Jefferson, Dr. Chen? Jeff is fine. Okay. Hey, Jeff. Yes. How's it going? Good. We're doing great. Good. So, I thought it'd be a good idea to have you on, and I'll frame it for all the listeners, or actually for our conversation points. The listenership is a lot of healthcare. Chiropractors, physical therapists, strength coaches, trainers. There are patients that kind of dabble through here. There's not as many. So, I thought you'd be a good person to have on when we're talking about ground-level falls and elderly, since you're so hyped on them.

Sound good? Great. Thank you for having me on your show. Yeah. Can you tell everyone a little bit about yourself, why you started getting into ground-level falls and whatnot? Right. Well, I'm a neurosurgeon by training, and as neurosurgeons, one of the key areas that we focus on is trauma. And when people think of trauma, they think of severe head injury, mostly. However, what the statistics and the demographics are showing, at least over the last several years, is that ground-level falls are increasingly becoming a common theme. And there's different reasons for this. I think one is that ground-level falls tend to occur in older patients.

And as we know, our population in general is aging, so we have a lot more elderly patients. And what we're finding is that these ground-level falls that occur, which traditionally people have thought were minor falls or there wasn't a lot of energy or kinetic energy behind the fall, actually, these falls can be very, very devastating to the patients. Mm-hmm. Where do the falls usually happen? Do you happen to ask the patients you get, like, were you in the living room, were you in the kitchen, bathroom? You got it right. It happens at home. So, somewhere at home, whether it's in the bedroom as they're getting out of bed or transitioning in the bathroom, it happens.

I think what we're finding is that there's some commonality of themes, usually when patients are transitioning from either sitting to standing position or laying to a standing position or when they're walking and they trip over something. Mm-hmm. So, there, but the bottom line is a lot of these falls occur in the home environment. It's interesting that it would happen at home. Like, I feel like that should be the most familiar environment to them, you know? Exactly. That's true. It's the most familiar environment to patients, but it's also where they spend the most time. Oh, right. It's like that car accident thing that happens within a mile of your house always because you're always within a mile of your house.

Right. I mean, go ahead. Oh, no, go ahead. You were going to say something. Well, you were saying about the accidents that happen in the house. And, yeah, it is in a common area or outside the house. Again, I think we'll talk a little bit more about some of the underlying potential causes for these falls, which inherently may be related to some neurological condition, whether it be dementia, whether it be Parkinson's, whether it be hydrocephalus. Some of those underlying problems can predispose a patient to have particular balance or gait problems. I did mention before I had you on in the introduction how we met in your workshop.

And I mentioned that when I was talking to the patients around, just everybody that just loved you, which I thought was a great thing because I don't know if you have Yelp reviews, but I don't know if everyone likes me, but everyone seemed to like you there. That means you're a great doc and you communicate really well. But Eliza said nothing but great things about you. Go ahead. Thank you for those great comments. I think you're referring to our support group meeting, which we had designed specifically for patients with this entity of normal pressure hydrocephalus. And I think part of it is these patients sort of bond to me because that is what I specialize in.

So I'm sort of speaking to the choir. These are people who perhaps have this entity or their family have this entity, and they really want to find out more about it because it's not something that is that necessarily well known. When did you finally start kind of getting into hydrocephalus as a trade, I guess? Because I looked up some stuff before I came to the workshop, and there wasn't a ton out there that I found. You know, it's kind of like a – it's not common. But anyways, how did you get into that? Well, I think that just backing up a little bit for some of your listeners who may not be familiar with normal pressure hydrocephalus or what we call NPH is the abbreviation for it.

It actually has been around – it was first identified back in the 1960s. And the classic symptomatology are basically threefold. Patients have trouble with their balance and walking. They have trouble with their memory and thinking. And they have trouble with bladder control. So those are the three sort of diagnostic cues that we look for to help make this diagnosis. And then on their CAT scans, they have big ventricles. So as neurosurgeons, we can do surgery to shunt these patients. And I think all of us are taught how to do these shunts when we're in our initial training. I became interested in this probably about 15 years ago when I was up in Portland, Oregon.

And up there, we had a lot of patients who we noticed had this entity. And we treated these patients. And shunts are one of the things we do. It's a very – pretty straightforward procedure. But when you see the patients improve with this, going from either being in wheelchairs or using a walker to being able to walk independently, it's tremendous. And while I was in Portland, I actually had a program up there for patients. Again, the same type of support group, which was, again, very, very well received by patients with this entity. How long does it usually take for them to feel benefits from the shunt being in?

It varies depending on the patient. And, again, one of the things about these patients, it seems that the peak age when this seems to manifest itself is in the 70s and 80s. And so many of these patients are actually rather deconditioned by the time they come to attention. So it takes a bit of time for them to get better. I think, invariably, most of the patients notice some improvement right away. However, they yearn for further improvement. And that comes with a lot of gait training, physical therapy, many of the things that you talked about at our workshop. Yeah, I was kind of curious with – I know there's certain populations that they – at least in my observation, they have a belief system or a belief about their body or their condition that sometimes will hinder them from doing the things that are recommended.

And I know that probably a lot of these people, since you have them in their 70s, do they ever think, well, I'm just getting older. This is a natural process. And by that, too, like I remember when I did give that presentation that there was people that participated, but I feel like the first couple of minutes it took some coaxing to get them to stand or do some effort. They didn't seem like they right away necessarily wanted to do it. Is there a – when you have this age group in this population, is there any of that hesitation to intervention of any type, physical or shunting? Absolutely. I think that – you're absolutely right.

I think that as patients age and as we all get older, there is more caution. And many of the patients will tell you, well, I'm just getting old. That's why I'm having this unsteadiness. That's why I can't stand on one foot. It's just natural. That's expected. And so they're a bit reticent to do some of those different exercises that you were talking about because they're not used to doing that. They have the attitude or the belief that at their particular age, they're not expected to be able to stand on one foot or to walk long distances without taking breaks. And unfortunately, if they also have on top of that this NPH, that will also make it difficult for them to walk.

So it becomes a struggle to lift up their feet. And a lot of – that is a neurological – has neurological underpinnings. Is there some type of conversation or test that you do with them that gets them to really buy into the concept that it's not just them aging, there's other underlying things, neurological things, that are creating their deficiencies? Well, I think that's part of what we do with our support group. Our support group. And also, when I see patients in clinic, we have a lot of education materials. We've created, for example, an iBook or electronic book for patients to look at. And it's got diagrams and pictures and video vignettes that show what other patients have been through or before and after examples of their walking.

And I think a lot of it is educating patients and their families about what they potentially can do and how they can improve with therapy and a shunt, for example. Cool. And people usually show up with their husband and wife or some type of other support, right? They don't show up alone? The majority of patients do show up, and we design it in such a way to have these support groups on a Saturday so that the patients who show up can bring their families. And again, most of these patients are older, so usually when they travel, they have somebody with them, either a spouse, a partner, or a family member.

Now, I might be digging myself a hole here because you'll probably get out of my ballpark, but what's the pathophysiology of the NPH creating all these problems? Is it the, because when you said the enlarged ventricles, I'm guessing that the, when I read the term normal pressure hydrocephalus, I think, well, there's normal pressure. How can there be any problems, you know? What's the process that occurs in the body to create all these neurological deficiencies? Right. That is a good question because I think even though it's been identified back in the 60s, to this date, there is debate on what is the underlying cause of this entity.

And to put it simply, I just, it's a neurodegenerative disorder. So basically, what is happening is the brain is degenerating or losing cells over time. And with this entity, what we find is the ventricles or the fluid-filled cavities in the brain, which are normal, everybody has them, dilate out. So the question is, why do they dilate out? Is it because the patients have lost X number of cells or an X number of brain cells over time, so you have a sort of vacuum phenomena? Or it's because there's some subtle extra pressure inside the brain, which is still normal, but it's a little bit extra, that causes the ventricles to dilate out.

The end result is that you have these large ventricles that you see. And the belief has been that these large ventricles lead to some stretch on the surrounding white metatracks, which leads to these classic symptoms of walking problems, thinking problems, and bladder control problems. But again, I think it's not that simple. It's rather complex as to, you know, the cause of it and which nerves are affected and why we see this symptomatology. Interesting. Is there, I was just thinking, is there any other conditions that have enlarged ventricles that the listeners might have already heard of before?

Or is this kind of like an isolated phenomena? Right. I mean, you can, in neurosurgery, we see a lot of people who have secondary hydrocephalus or secondary NPH. And those are patients who have had, for example, a head injury in the past, or they've had a stroke, or they've had a tuber. So, some type of brain tumor, for example. So, what the belief is, these other entities somehow change the flow of spinal fluid in the brain that ultimately leads to the dilation and very similar symptoms that we have with NPH. In fact, that's called secondary NPH as opposed to idiopathic, meaning we don't know what causes the NPH.

Hmm. Okay. Is there, what do people typically try if they've had these symptoms, and they're like, well, and they read an article on NPH, and they're like, well, I think I have that, but I don't want to do the shunt yet. What are some things that they typically try, and is there any success in those, or is there no success? So, that's a good question. We have a lot of patients who are early on in the course of NPH. That means they're found early on. They have maybe some subtle findings, or maybe this CAT scan of the brain was done for some other reason. They found these big ventricles, but they don't have the full-blown triad of symptoms.

So, many of these patients, we watch them, we observe them, and we follow them serially with neurological examinations. And those patients who have perhaps some gait problems, we will have them seen by physical therapy, and physical therapists will give them exercises specifically for gait training to help them with their mobility. Do they, in your observation, what's the success rate of getting people to start really having normal gait again, or at least kind of getting out of the woods of having, because I know we talked about falls in the beginning. How long should someone really expect? I know I might have mentioned this in the workshop a little bit with people, but I don't work with that population set very often.

So, I'm just kind of curious what you observe. Right. I think that if the patients are early on in the process, it can attenuate the course, the natural history or the course of NPH significantly, even by a couple years or so, that it will slow the process. And, you know, why is that? The question is, why is it slowing the process? Is it just the patient's muscles work better or the coordination is better? They've learned to compensate for it? Or is there something else going on? As we know from numerous studies, exercise and movement is the best thing for neurological degenerative disorders of the brain.

That all the Alzheimer's studies, for example, show that patients who do more exercise do better. Mm-hmm. Yeah. It's funny. In my realm, with the people I work with, they'll come in with, like, knee issues and back ones and all these different types of things. And through all the readings that I've done in just my clinical observation is when people rest too long, they get worse. And when they start moving a little bit, at least a graded exposure, they seem to get better. And I spoke with someone. I interviewed a concussion guy a couple weeks back. And when I started learning about concussions, there was this graded exposure back into returning to play.

And the first part was you just sit in a dark room, don't look at any screens until your symptoms start to dissipate. And he was, I hadn't been well-versed on concussions in a while because I don't really manage them. And he was proposing the concept that movement, even as early as the first day, at least the first 10 days, you get them on a treadmill and get them walking, they seem to get better. And it was surprising to me because with brain injuries, I've always been taught that we're a little bit more on guard with it. And with musculoskeletal, it's like you can just start pushing them a little bit more, but then you monitor the symptoms.

So it's interesting to hear you say that, you know, you just, just the benefits of general exercise and movement. Because I think in the past when I learned that kind of stuff, it was, they're a little bit more of, like, taboo, be aware. Like, these are special, special, special cases, you know? Right. I think there's a lot we're learning about how mobility or movement or activity affects the brain and how the brain functions. There's a lot of new data that suggests that the flow of fluid through the brain or the movement of spinal fluid or interstitial spinal fluid through the brain is greatly affected by activity.

Whether patients are moving, whether they're exercising, whether they're sleeping, there's different patterns of flow through the brain. Is there, is there, is that a mechanical based system or, because I, like, say lymph is, is being pushed back by mechanical, muscular squeezing, right? Or how does the, how's the, how's the fluid work in there? I don't, I actually don't know. I, I, I don't think we know for sure how it is. Is it, you know, is it, like you say, is it a mechanical thing or is it that the brain's more active because you're, it's sensing the movement of the, of the limbs and that's metabolically more active?

Or are the, uh, absorbance pathways in the brain altered by movement? Uh, and thus you clear out some of the waste products or metabolic products. Um, those are very, very hot areas of research, you know, even as, as we speak right now. Okay. Um, before you came on, actually this morning, I was looking up some research on, um, uh, ground level falls and I pulled up this one, uh, article, which was, they, they quoted some stats and I, I found them to be a little, I found them to be interesting that after ground level falls and elderly, they, they said 12% of, of death on a mission, uh, 51% discharged a skilled nursing facility, 33% sent home without assistance.

Um, and within a year, 44% have readmittance. Um, I saw the 33% was actually surprising to me based upon how high the readmittance rate is there. I know Eliza's talked to me about this a bit that the discharge orders of people and do the people have, um, appropriate, um, help or finances or insurance to help them kind of get over this. That's a type of, uh, recovery process after a fall. Um, what do you, what do you think on that kind of stuff? Right. The, you know, you're right. The, the readmission rate is, is pretty high. I mean, so, so the question is why do these people have, you know, another readmission?

Is it because they've had another ground level fall? Uh, do they stumble again? And, and I think the data shows that yes, that, that patients who have had a fall are sort of prone to having another fall. And why is that? It's because they, have they injured themselves? Have they hurt their, their ankle, their foot? Have they hurt their hip? Have they had surgery because this, or is it because there's a brain injury? And I think all of those, all of those apply. And, uh, obviously if somebody's had such an injury, they're going to be, they're going to have a little more trouble getting back, uh, to normality.

And that's, they're at risk for falling again. And, and I think as, as you mentioned, Eliza had mentioned that, uh, you know, whatever we can do to try to, uh, mitigate those falls is, is going to be key. Yeah. I know that with, um, are people sent home with, with instructions of things to do or, uh, also to, do, do they get access to, like, a therapist coming over, a coach or a trainer coming over or something like that? Right. All of those resources in the ideal situation, uh, are, are good. And that's, and that's what we want our patients to have, that they have instructions that the therapists work with them at home or work with the families at home to train them.

Uh, but on top of that, uh, you know, do they have therapists who come in and see them and, and give them additional, uh, treatment or do they have outpatient therapy? I mean, all that is, is something that, uh, really is, is, is, uh, I can't stress enough. I can't stress enough how important that is for getting patients back onto their, their feet and, and particularly the older patients. Not, not necessarily, uh, I mean, I think that's one of the focuses that a lot of the older patients need a lot more extra help. I mean, I would, I would, I mean, I'd venture to even say like on a daily basis, it's just way more frequency than I would see, you know, someone in their thirties for most things.

Um, but the one thing I, uh, my experience of working with the, uh, or going in the workshop was that, um, a lot of people came up and asked me after the presentation, they were talking about, uh, cost and insurance and so on. And, uh, I just told them like, look, we're not, I like, we're a small office. We don't bill insurance really. And, um, they, they really had a lot of questions about where they can get access to things with, uh, insurance coverage. And I know it's a long conversation to probably have with them at that point. And, but I always tell people that come in here that, that need is not based upon what your third party will dictate.

Um, and I'm guessing that, I mean, at least with, with my experience with elderly, it's like every day, just even having a buddy to like get them out of bed would be nice, but maybe an insurance won't pay for them to come for help to come every day. So, and I just told them at the end right there, I said, look, it's, I'm like, sometimes you got to pay for stuff and even like a trainer or a coach would be, would be helpful to, to implement some barely, um, some small like entry points. Like what, like the examples that I did on the chair and the table. But, um, do you ever have, I guess my question is, do you have people who push back about cost?

Cause this is a very, this is, this is a disabling thing. You know, if you can't get out of bed and can't walk and can't get to the restroom, you know? Right. Um, that is, that is one of the, uh, age old questions about how much will be covered by insurance. And most of the patients, um, that we deal with in the older group are, are Medicare. And Medicare has limited number of, uh, physical therapy sessions that they will fund. And I think that's, that's where the importance of what, what you've been doing with a lot of your, your podcasts and all is that there are a lot of things patients and their families can do on their own.

Simple, uh, simple, uh, simple, uh, exercises that can have, that they can do on their own once they're trained that can have profound, profound, uh, health benefits or balance benefits, uh, you know, for specifically if they're having trouble with their walking, for example. Mm-hmm. When, when they ask you for a single recommendation, what do you, what do you show them? What's your, what's your go-to one thing? I can imagine you like demonstrating some type of exercise in the office. You mean so if I, if I were to ask, if they were to ask me what kind of exercise to do? Yeah, because you're, because you're the trusted source to them.

They probably ask you everything. Right, well, I, I always tell them that, that if all they do is walk, okay, with a walker or with a family member and just, just get, you know, across the room, all right? That is a major, major accomplishment, particularly for some of the patients who are recovering from surgery. So, a lot of times, patients who are coming from this shunt surgery, I'm talking about specifically, a lot of them think they should be able to just get up and get going right away. And I tell them that it's, it's taken them probably several years to get deconditioned, so they're going to need to get reconditioned.

Mm-hmm. And, and one of the big focuses we have, first, when they're in the hospital, is getting them up, getting them walking with a walker if necessary, and just get that process going. And if all they do is just keep focusing on that, focusing on that, they will gradually, incrementally improve. Yeah, it, it's, it's funny, it's funny you say they want to get up and, and start going really far and really fast, really quickly. Um, I'd say probably the major reason why I'm in business is because people, I mean, I'd love them to be, to be ambitious, but there's like big spikes in their activity level.

So, they're just, the rest of their body is not conditioned enough for that, and they end up having another problem, you know. But, I'm glad they're ambitious like that. So, I love the walker recommendation. That's like the simplest thing to do. Right. It's simple, and it's something that, you know, family are familiar with, and obviously there are little nuances to it. But, um, it's so familiar, and, and it's something that, if they can walk, it makes a big difference. Mm-hmm. Um, is there, I know, so we've gone over ground-level falls, we've gone over reasons for ground-level falls. Did we, did we miss other common reasons in there?

Do you think that, that we need to touch on that, with that? Some, the reasons for ground-level falls? Yeah, we went over NPH, and then, I think, uh, just deconditioning, I think is the main two. Right. I, I think one of the things that, um, that we're very interested in is, is the role of NPH in ground-level falls. So, if we think about it, if you look at sort of the national, or national statistics about, you know, how many people have potentially NPH, in the U.S., it's about 500,000 to 700,000. Okay, those are sort of, what are the natural numbers you, any paper you pick up will say that's about how many people, uh, potentially have that in the U.S.

All right, now, the question is, uh, how often is it detected? And, the problem is, sometimes it's not detected, because, well, it may fester for many years before it becomes evident, or maybe it's, or maybe it's misdiagnosed. What we have found in, in looking at, sort of, our trauma patients who come through, and, you know, we're a level one trauma center, so we see a lot of trauma, is if we looked at our ground-level falls, and this is a, a study that we're doing, and look at our ground-level falls, and go back and look at the CAT scans on those people who had ground-level falls who hurt their head, okay, right, so they had a CAT scan.

A large percentage of them have large ventricles, which would let you be suspicious that, perhaps, um, they have NPH. And, obviously, that's something that we're investigating further, but NPH, you may ask, why, why is that, why does that contribute to ground-level falls? I think, anytime anybody has problems with their balance or walking, they can fall. Mm-hmm. You must have a bunch of data on that. You must get, how many, how many falls do you guys get in there a month? Oh, uh, ground-level falls, we, we have a tremendous number. I, I don't know the exact number, but any, any given day, there's probably two or three who have a ground-level fall who hit their head.

Okay, but think about all the ground-level falls who fall on their wrist, or on their knee, or on their ankle, or on their hip. Uh, and most of the statistics show that, uh, the two areas, when people fall, that they hurt, are, when they're elderly, are hips and head. How come they don't get their arm out quicker? Or is it, are they, are they on a cane or a walker, where they're still holding on to that thing? Because I feel like that would be a reactionary thing. Right. Um, but I think, I think, it's, it's sort of, you're right, you would think they would, they would put their hands up and try and break the fall, but don't forget that the, the hip and leg areas, a big, a big surface area, for example, that can, can be hit, can impact.

We just got to get them, get some more fat on the side of the, uh, hip, then we'll just, no, they'll probably then roll onto their head. Right. The mechanics of falls. Um, so, uh, I looked up a couple of things, too, uh, in regards to, uh, ground level falls. So, you're probably looking for subdural hematomas, and I looked up, there was chronic subdural hematomas. I, uh, I know this might be a tangent to the conversation, but I had to ask you. There's, I'm guessing there's acute and chronic. What is a, what is a chronic subdural hematoma? That, that's a, um, good question. The, the, an acute subdural hematoma means that there's blood there that you see right away, that it happened right at that fall.

What happens very commonly, again, with older patients, is they can get what's called a chronic subdural hematoma. So, what that is, is the process starts. They have a small bleed that is not devastating. Okay, so there's a little bit of blood that you can see in a CAT scan, but it's not enough that you do an operation for it. What happens is, that fluid there, or that blood, starts an inflammatory reaction. Okay, that inflammatory reaction will fester there, and they'll form scar or membranes in there, as the body tries to wall off that blood away from the brain, and that gets larger and larger, and it gets large enough that it has to ultimately be drained via surgery.

Oh. Got it. So, then, they might have a secondary increased, increased size of their ventricles. Those would be those people? Right. That's possible that they can, as a result of some, again, absorbance problem or flow of spinal fluid problem down the line, they may have problems and may develop a hydrocephalus. And many of the patients, you know, have hydrocephalus also, to start with. Okay. Or big ventricles, let's say. So, before we round back into, like, just tying things together, because we've gone a couple different routes, can you describe the procedure for the NPH and how that kind of goes for everyone who doesn't know?

I saw shunts on people, and I'd never seen them before, so I'd like to know as well. So, the procedure for NPH basically is putting in a shunt. So, what the shunt means is you're diverting fluid from the ventricle in the brain down into the abdomen. Okay. So, in the abdomen, in the space outside of the intestines and stomach, this is called the peritoneal space, is a large surface area that will absorb the fluid. And so, the process is basically you're creating a tunnel from the head, and usually we select a spot where we drill a hole to the skull and put a catheter about five centimeters down into the brain, where it will then drain the ventricles.

And there is a shunt or the valve is a special designed component which has evolved over the last many years to the point that now you can adjust or change the valve to change the amount of fluid that is drained. And that center intervenes. So, you put that in line, and then the rest of the tubing goes down behind the ear, across the clavicle, and down into the peritoneum. And that's all under the skin. So, everything's under the skin. So, you actually don't see the shunt or the tube. So, what happens if the calibration is, it drains too quickly? What kind of symptoms happen with that? Yeah, that's, one of the temptations is to try to drain a lot.

Because the thought is that, well, if there's too much fluid, and you drain more off, you get better faster. However, what that does, it increases the risk of that subdural hematoma or chronic subdural hematoma, because the brain then falls away from the skull, creating a potential space where blood can accumulate. So, that can happen if you drain too much. That's why we tend to adjust and tighter the drainage. There's so many little factors. Do you sleep at night? Pardon me? Can you sleep at night, thinking of all these little factors? Well, we plan everything out really carefully, so that we can optimize this for the patients.

And, you know, knock on wood, thus far, we've been very, very fortunate and have had a very good success rate. Nice. So, as we start to wrap up here, we went from ground-level falls and elderly, the reasons for the ground-level falls, and then secondary consequences, as well as ways to mitigate the risk of having the fall or slow the process of having to deal with NPH surgically via gait and movement. Does that sound correct? That's correct. Okay. Anything you'd like to add? Again, I think one of the things that we've talked about that is, you know, one of the take-home messages, are there are a lot of ground-level falls, and part of that has to do with our population growth and that we're having older population, and as you have older, more elderly patients, they're going to be prone to falling, and many of these patients are on anticoagulants like Coumadin or Eliquis or any other anticoagulants, which also increases the risk of problems or head injuries or bleeding in the brain.

So, I think the whole problem of ground-level falls is really tremendous and enormous, and I think we all have to work together to try and find better ways to take care of it. So, I guess lastly, what do you think a good role for, like, a physical therapist, maybe a chiropractor, a coach, a trainer, what do you think are ways that they can help these populations that you've seen? I think it's tremendous. I think it's training both the population as well the caregivers for this population. I think knowing what the pitfalls are, knowing where are the common ways or the common reasons for people falling, and then trying to obviate that by teaching them perhaps how to lift up their feet, how to get their feet up above the curb, how to turn, how to balance.

All these things, I think, are ways that therapists, chiropractors can help to educate this at-risk population. Okay. And I guess lastly, what about the caregiver? Is there any certain things the caregivers should know? Because they're going to be, I'm guessing, family members, and in my observation, family members giving advice to family members sometimes yields emotional responses more so than clinicians or healthcare doing it. Do you have any advice for the caregiver? Well, I think the caregivers are key and really important in the training of the patients and in their recovery, too, if they have a fall or if they have an injury or if they have surgery.

But many times the caregivers are contemporaries of the patients, and so they have to be careful of themselves, too. They have to sort of know when to get additional help because they will get burned out also. They will get tired. They can hurt themselves, too, by lifting or pulling or trying to help the patient. And so I think they have to be sensitive to that, too. And I think that, you know, the caregivers have to be able to reach out and get sort of a whole community of people to help out. Nice. Is there any way that the listeners could reach out to you? Do you have a website, any email, or social media you'd like to share?

I don't actually do social media. I love that. I wish I could do the same. I'm of a generation that didn't really learn how to adopt it, so I don't have social media. However, the UC Irvine website is very active, and there's links to my office. And we also have links to some of the electronic material or iBook material that we've created on head injury, falls, and pH. Cool. I can send to you. Yeah, cool. I'll list those in the website show notes so everyone can have a direct link to that. So I'll try to make it easy for everybody. All right, great. Thank you so much for being on. I learned a lot, so now I can bug Eliza more about NPH.

Well, thank you for having me on. Anytime. Thank you. Thank you so much, Dr. Jeff, for being on. That was amazing. And I think that you all are going to get a lot from that. I got a lot from that. I learned a lot. So hopefully you did, too. Remember, share this with a friend if you feel like, wow, that was good information. I want to share this. I want to share this with the world. It's kind of like doing a Yelp review. You don't need to comment on that chimichanga you got, but you feel the need to share with the world. Do the same thing with this. If you're looking for the show notes on this, go to p2sportscare.com and just type up Jeff Chen's name.

Or just look at your phone. Your phone's going to be scrolling across with the title of this podcast as well as a number. Don't include the hashtag. Just put the number in. I'm not sure what number this is actually right now. I know it's in the 120s. So go through and just type that in on the search bar on the website and you'll come up with all the show notes for this and any links that we spoke about. Again, if you have any guests that you would like me to interview, just let me know. I would love to meet more and more people. Now, last thing, housekeeping, is if you heard last episode, there was a book preview.

And the book preview was, again, it was the book that I just created. I've spent the last year creating it, so I'm very passionate about it. There's a lot of books and programs out there which will discuss how to get over back pain and how to implement this and how to use that and how to stretch this and strengthen that and blah, blah, blah. I didn't even do that. I actually did in the beginning, I created a book, actually a whole manual, a manuscript. It was like 250 pages about the things that I would do with someone on day one and so on, but no one read it. Like I sent it to five people and then they said it was too long.

So I realized at that point there's a mental barrier of people with back problems and a lot of conditions in general. They need to hit the point of inception. They need to be conditioned to goal set and they need to be able to visualize their life without that problem. So that's all what this book is. So if you have a loved one, a spouse, a husband, a wife, a brother, a sister, a father, a mother with back problems that just every single time you see them they talk about it or they grimace when they stand up and they don't ask for help and when help is given to them they don't take it, buy them this book.

So that book will be available on Amazon in print, audio, and ebook. If you do buy it, please give it a review. Give it a testimonial. If it's worked for whoever you give it to, I would love that. And again, the only way to get good information out there is to talk about it. So if you're enjoying all of the podcasts and if you're enjoying the book, when you read the book, tell people about it. I'll put a link to the book in the show notes. But as always, I'll talk to you guys soon. Leave people better than how you found them. And if your daughter is dating, tell them to date an Eagle Scout because they're badass.

Talk to you later.