The Journal of Family Practice

CASE Mr. J, a 75-year-old man, presents to your family practice reporting that he feels increasingly unsteady and slow while walking. He fell twice last year, without resulting injury. He now worries about tripping while walking around the house and relies on his spouse to run errands.

Almost 30% of people older than 65 years report 1 or more falls annually.

Clearly, Mr. J is experiencing a problem with balance. What management approach should you undertake to prevent him from falling?

Copyright Scott Bodell

Balance disorders are common in older people and drastically hinder quality of life.^1-4 Patients often describe imbalance as vague symptoms: dizziness, unsteadiness, faintness, spinning sensations.^5,6 Importantly, balance disorders disrupt normal gait and contribute to falls that are a major cause of disability and morbidity in older people. Almost 30% of people older than 65 years report 1 or more falls annually.⁷ Factors that increase the risk of falls include impaired mobility, previously reported falls, reduced psychological functioning, chronic medical conditions, and polypharmacy.^7,8

The cause of any single case of imbalance is often multifactorial, resulting from dysfunction of multiple body systems (TABLE 1^7-56); in our clinical experience, most patients with imbalance and who are at risk of falls do not have a detectable deficit of the vestibular system. These alterations in function arise in 3 key systems—vision, proprioception, and vestibular function—which signal to, and are incorporated by, the cerebellum to mediate balance. Cognitive and neurologic decline are also factors in imbalance.

Considering that 20% of falls result in serious injury in older populations, it is important to identify balance disorders and implement preventive strategies to mitigate harmful consequences of falls on patients’ health and independence.^7,57 In this article, we answer the question that the case presentation raises about the proper management approach to imbalance in family practice, including assessment of risk and rehabilitation strategies to reduce the risk of falls. Our insights and recommendations are based on our clinical experience and a review of the medical literature from the past 40 years.

CASE Mr. J has a history of hypertension, age-­related hearing loss, and osteoarthritis of the knees; he has not had surgery for the arthritis. His medications are antihypertensives and extra-strength acetaminophen for knee pain.

Making the diagnosis of a balance disorder

History

A thorough clinical history, often including a collateral history from caregivers, narrows the differential diagnosis. Information regarding onset, duration, timing, character, and previous episodes of imbalance is essential. Symptoms of imbalance are often challenging for the patient to describe: They might use terms such as vertigo or dizziness, when, in fact, on further questioning, they are describing balance difficulties. Inquiry into (1) their use of assistive walking devices and (2) development or exacerbation of neurologic, musculoskeletal, auditory, visual, and mood symptoms is necessary. Note the current level of their mobility, episodes of pain or fatigue, previous falls and associated injuries, fear of falling, balance confidence, and sensations that precede falls.⁵⁸

Continue to: The medical and surgical histories

The medical and surgical histories are key pieces of information. The history of smoking, alcohol habits, and substance use is relevant.

A robust medication history is essential to evaluate a patient’s risk of falling. Polypharmacy—typically, defined as taking 4 or more medications—has been repeatedly associated with a heightened risk of falls.^53,59-61 Moreover, a dose-dependent association between polypharmacy and hospitalization following falls has been identified, and demonstrates that taking 10 or more medications greatly increases the risk of hospitalization.⁵⁹ Studies of polypharmacy cement the importance of inquiring about medication use when assessing imbalance, particularly in older patients.

Physical examination

A focused and detailed physical examination provides insight into systems that should be investigated:

• Obtain vital signs, including orthostatic vitals to test for orthostatic hypotension⁶²; keep in mind that symptoms of orthostatic dizziness can occur without orthostatic hypotension.
• Examine gait, which can distinguish between causes of imbalance (TABLE 2).^21,40,63-70
• Perform a cardiac examination.
• Assess visual acuity and visual fields; test for nystagmus and identify any optic-nerve and retinal abnormalities.
• Evaluate lower-limb sensation, proprioception, and motor function.
• Evaluate suspected vestibular dysfunction, including dysfunction with positional testing (the Dix-Hallpike maneuver⁷¹). The patient is taken from sitting to supine while the head is rotated 45° to the tested side by the examiner. As the patient moves into a supine position, the neck is extended 30° off the table and held for at least 30 seconds. The maneuver is positive if torsional nystagmus is noted while the head is held rotated during neck extension. The maneuver is negative if the patient reports dizziness, vertigo, unsteadiness, or “pressure in the head.” Torsional nystagmus must be present to confirm a diagnosis of benign paroxysmal positional vertigo.
• If you suspect a central nervous system cause of imbalance, assess the cranial nerves, coordination, strength, and, of course, balance.

CASE

Mr. J’s physical examination showed normal vital signs without significant postural changes in blood pressure. Gait analysis revealed a slowed gait, with reduced range of motion in both knees over the entire gait cycle. Audiometry revealed symmetric moderate sensorineural hearing loss characteristic of presbycusis.

Diagnostic investigations

Consider focused investigations into imbalance based on the history and physical examination. We discourage overly broad testing and imaging; in primary care, cost and limited access to technology can bar robust investigations into causes of imbalance. However, identification of acute pathologies should prompt immediate referral to the emergency department. Furthermore, specific symptoms (TABLE 1^7-56) should prompt referral to specialists for assessment.

Continue to: In the emergency department...

In the emergency department and academic hospitals, key investigations can identify causes of imbalance:

• Electrocardiography and Holter monitoring test for cardiac arrhythmias.
• Echocardiography identifies structural abnormalities.
• Radiography and computed tomography are useful for detecting musculoskeletal abnormalities.
• Bone densitometry can identify osteoporosis.
• Head and spinal cord magnetic resonance imaging can be used to identify lesions of the central nervous system.
• Computed tomographic angiography of the head and neck is useful for identifying stroke, cerebral atrophy, and stenotic lesions of the carotid and vertebral arteries.
• Nerve conduction studies and levels of serum vitamin B₁₂, hemoglobin A1C, thyroid-stimulating hormone, and random cortisol can uncover causes of peripheral neuropathy.
• Bedside cognitive screening tests can be used to measure cognitive decline.⁷²
• Suspicion of vestibular disease requires audiometry and vestibular testing, including videonystagmography, head impulse testing, and vestibular evoked myogenic potentials.

In many cases of imbalance, no specific underlying correctable cause is discovered.

Management of imbalance

Pharmacotherapy

Targeted pharmacotherapy can be utilized in select clinical scenarios:

• Medical treatment of peripheral neuropathy should target the underlying condition.
• Cognitive behavioral therapy and antidepressants are useful for treating anxiety and depressive disorders.⁷³
• Musculoskeletal pain can be managed with acetaminophen and topical nonsteroidal anti-inflammatory drugs (NSAIDs), using a short course of an oral NSAID when needed.⁷⁴
• Cardiovascular disease management might include any of several classes of pharmacotherapy, including antiplatelet and lipid-lowering medications, antiarrhythmic drugs, and antihypertensive agents.
• Acute episodes of vertigo due to vestibular neuritis or labyrinthitis can be managed with an antiemetic.⁴⁶

Surgical treatment

Surgery is infrequently considered for patients with imbalance. Examples of indications include microsurgical resection of vestibular schwannoma, resection of central nervous system tumors, lens replacement surgery for cataract, surgical management of severe spinal fracture, and hip or knee arthroplasty in select patients.

Tools for assessing the risk of falls

Scoring systems called falls risk assessment tools, or FRAT, have been developed to gauge a patient’s risk of falling. The various FRATs differ in specificity and sensitivity for predicting the risk of falls, and are typically designed for specific clinical environments, such as hospital inpatient care or long-term care facilities. Specifically, FRATs attempt to classify risk using sets of risk factors known to be associated with falls.

Continue to: Research abounds into...

In our experience, most patients with imbalance and who are at risk of falls do not have a detectable deficit of the vestibular system.

Research abounds into the validity of commonly used FRATs across institutions, patient populations, and clinical environments:

The Johns Hopkins FRAT^a determines risk using metrics such as age, fall history, incontinence, cognition, mobility, and medications⁷⁵; it is predominantly used for assessment in hospital inpatient units. This tool has been validated repeatedly.^76,77

Peninsula Health FRAT^b stratifies patients in subacute and residential aged-care settings, based on risk factors that include recent falls, medications, psychological status, and cognition.⁷⁸

FRAT-up^c is a web-based tool that generates falls risk using risk factors that users input. This tool has been studied in the context of patients older than 65 years living in the community.⁷⁹

Although FRATs are reasonably useful for predicting falls, their utility varies by patient population and clinical context. Moreover, it has been suggested that FRATs neglect environmental and personal factors when assessing risk by focusing primarily on bodily factors.⁸⁰ Implementing a FRAT requires extensive consideration of the target population and should be accompanied by clinical judgment that is grounded in an individual patient’s circumstances.⁸¹

Continue to: Preventing falls in primary care

An approach to preventing falls includes the development of individualized programs that account for frailty, a syndrome of physiologic decline associated with aging. Because frailty leads to diminished balance and mobility, a patient’s frailty index—determined using the 5 frailty phenotype criteria (exhaustion, weight loss, low physical activity, weakness, slowness)⁸² or the Canadian Study of Health and Aging Clinical Frailty Scale⁸³—is a useful tool for predicting falls risk and readmission for falls following trauma-related injury. Prevention of falls in communities is critical for reducing mortality and allowing older people to maintain their independence and quality of life.

Exercise. In some areas, exercise and falls prevention programs are accessible to seniors.⁸⁴ Community exercise programs that focus on balance retraining and muscle strengthening can reduce the risk of falls.^73,85 The Choosing Wisely initiative of the ABIM [American Board of Internal Medicine] Foundation recommends that exercise programs be designed around an accurate functional baseline of the patient to avoid underdosed strength training.⁵⁴

Multifactorial risk assessment in high-risk patients can reduce the rate of falls. Such an assessment includes examination of orthostatic blood pressure, vision and hearing, bone health, gait, activities of daily living, cognition, and environmental hazards, and enables provision of necessary interventions.^73,86 Hearing amplification, specifically, correlates with enhanced postural control, slowed cognitive decline, and a reduced likelihood of falls.^87-93 The mechanism behind improved balance performance might be reduced cognitive load through supporting a patient’s listening needs.^88-90

Pharmacotherapy. Optimizing medications and performing a complete medication review before prescribing new medications is highly recommended to avoid unnecessary polypharmacy^7,8,18,53-56 (TABLE 1^7-56).

Management of comorbidities associated with a higher risk of falls, including arthritis, cancer, stroke, diabetes, depression, kidney disease, chronic obstructive pulmonary disease, cognitive impairment, hypertension, and atrial fibrillation, is essential.^94-96

Continue to: Home safety interventions

Home safety interventions, through occupational therapy, are important. These include removing unsafe mats and step-overs and installing nonslip strips on stairs, ­double-sided tape under mats, and handrails.^73-97

Screening for risk of falls. The Centers for Disease Control and Prevention recommends that (1) all patients older than 65 years and (2) any patient presenting with an acute fall undergo screening for their risk of falls.⁹⁸ When a patient is identified as at risk of falling, you can, when appropriate, assess modifiable risk factors and facilitate interventions.⁹⁸ This strategy is supported by a 2018 statement from the US Preventive Services Task Force⁹⁹ that recommends identifying high-risk patients who have:

• a history of falling
• a balance disturbance that causes a deficit of mobility or function
• poor performance on clinical tests, such as the 3-meter Timed Up and Go (TUG) assessment (www.cdc.gov/steadi/pdf/TUG_test-print.pdf).

In addition to visual, proprioception, and vestibular dysfunction, cognitive and neurologic decline are also factors in imbalance.

An increased risk of falls should prompt you to refer the patient to community programs and physiotherapy in accordance with the individual’s personal goals⁹⁹; a balance and vestibular physiotherapist is ideally positioned to accurately assess and manage patients at risk of falls. Specifically, the Task Force identified exercise programs and multifactorial interventions as being beneficial in preventing falls in high-risk older people.⁹⁹

Balance assessment and rehabilitation in specialty centers

Polypharmacy— typically, defined as taking 4 or more medications— has been repeatedly associated with a heightened risk of falls.

An individualized rehabilitation program aims to restore safe mobility by testing and addressing specific balance deficits, improving functional balance, and increasing balance confidence. Collaboration with colleagues from physiotherapy and occupational therapy aids in tailoring individualized programs.

Many tests are available to assess balance, determine the risk of falls, and guide rehabilitation:

• The timed 10-meter walk test^d and the TUG test are simple assessments that measure functional mobility; both have normalized values for the risk of falls. A TUG time of ≥ 12 seconds suggests a high risk of falls.
• The 30-second chair stand^e evaluates functional lower-extremity strength in older patients. The test can indicate if lower-extremity strength is contributing to a patient’s imbalance.
• The modified clinical test of sensory interaction in balance^f is a static balance test that measures the integrity of sensory inputs. The test can suggest if 1 or more sensory systems are compromised.
• The mini balance evaluation systems test^g is similar: It can differentiate balance deficits by underlying system and allows individualization of a rehabilitation program.
• The functional gait assessment^h is a modification of the dynamic gait index that assesses postural stability during everyday dynamic activities, including tasks such as walking with head turns and pivots.
• The Berg Balance Scaleⁱ continues to be used extensively to assess balance.

Continue to: The mini balance evaluation systems test...

All patients older than 65 years and any patient presenting with an acute fall should undergo screening for their risk of falls.

The mini balance evaluation systems test, functional gait index, and Berg Balance Scale all have normative age-graded values to predict fall risk.

CASE

Mr. J was referred for balance assessment and to a rehabilitation program. He underwent balance physiotherapy, including multifactorial balance assessment, joined a community exercise program, was fitted with hearing aids, and had his home environment optimized by an occupational therapist. (See examples of “home safety interventions” under “Preventing falls in primary care.”)

Exercise programs should be designed around an accurate functional baseline of the patient to avoid underdosed strength training.

3 months later. Mr. J says he feels stronger on his feet. His knee pain has eased, and he is more confident walking around his home. He continues to engage in exercise programs and is comfortable running errands with his spouse.

CORRESPONDENCE
Jason A. Beyea, MD, PhD, FRCSC, Division of OtolaryngologyHead and Neck Surgery, Queen’s University, 144 Brock Street, Kingston, Ontario, Canada, K7L 5G2; jason.beyea@queensu.ca

^awww.hopkinsmedicine.org/institute_nursing/models_tools/jhfrat_acute%20care%20original_6_22_17.pdf

^bhttps://content.health.vic.gov.au/sites/default/files/migrated/files/collections/policies-and-guidelines/b/b2b_1a_frat_pdf.pdf

^cwww.ncbi.nlm.nih.gov/pmc/articles/PMC4376110/figure/figure14/?report=objectonly

^dwww.neuropt.org/docs/default-source/cpgs/core-outcome-measures/core-measure-10-meter-walk-test-(10mwt)_final.pdf?sfvrsn=c5585243_2&sfvrsn =c5585243_2

^ewww.cdc.gov/steadi/pdf/STEADI-Assessment-30Sec-508.pdf

^fwww.mdapp.co/mctsib-modified-clinical-test-of-sensory-interaction-in-balance-calculator-404/

^gwww.sralab.org/sites/default/files/2017-07/MiniBEST_revised_final_3_8_13.pdf

^hwww.neuropt.org/docs/default-source/cpgs/core-outcome-measures/function-gait-assessment-pocket-guide-proof9-(2).pdf?sfvrsn=b4f35043_0

ⁱwww.ncbi.nlm.nih.gov/books/NBK574518/

CASE Mr. J, a 75-year-old man, presents to your family practice reporting that he feels increasingly unsteady and slow while walking. He fell twice last year, without resulting injury. He now worries about tripping while walking around the house and relies on his spouse to run errands.

Almost 30% of people older than 65 years report 1 or more falls annually.

Clearly, Mr. J is experiencing a problem with balance. What management approach should you undertake to prevent him from falling?

Copyright Scott Bodell

Balance disorders are common in older people and drastically hinder quality of life.^1-4 Patients often describe imbalance as vague symptoms: dizziness, unsteadiness, faintness, spinning sensations.^5,6 Importantly, balance disorders disrupt normal gait and contribute to falls that are a major cause of disability and morbidity in older people. Almost 30% of people older than 65 years report 1 or more falls annually.⁷ Factors that increase the risk of falls include impaired mobility, previously reported falls, reduced psychological functioning, chronic medical conditions, and polypharmacy.^7,8

The cause of any single case of imbalance is often multifactorial, resulting from dysfunction of multiple body systems (TABLE 1^7-56); in our clinical experience, most patients with imbalance and who are at risk of falls do not have a detectable deficit of the vestibular system. These alterations in function arise in 3 key systems—vision, proprioception, and vestibular function—which signal to, and are incorporated by, the cerebellum to mediate balance. Cognitive and neurologic decline are also factors in imbalance.

Considering that 20% of falls result in serious injury in older populations, it is important to identify balance disorders and implement preventive strategies to mitigate harmful consequences of falls on patients’ health and independence.^7,57 In this article, we answer the question that the case presentation raises about the proper management approach to imbalance in family practice, including assessment of risk and rehabilitation strategies to reduce the risk of falls. Our insights and recommendations are based on our clinical experience and a review of the medical literature from the past 40 years.

CASE Mr. J has a history of hypertension, age-­related hearing loss, and osteoarthritis of the knees; he has not had surgery for the arthritis. His medications are antihypertensives and extra-strength acetaminophen for knee pain.

Making the diagnosis of a balance disorder

History

A thorough clinical history, often including a collateral history from caregivers, narrows the differential diagnosis. Information regarding onset, duration, timing, character, and previous episodes of imbalance is essential. Symptoms of imbalance are often challenging for the patient to describe: They might use terms such as vertigo or dizziness, when, in fact, on further questioning, they are describing balance difficulties. Inquiry into (1) their use of assistive walking devices and (2) development or exacerbation of neurologic, musculoskeletal, auditory, visual, and mood symptoms is necessary. Note the current level of their mobility, episodes of pain or fatigue, previous falls and associated injuries, fear of falling, balance confidence, and sensations that precede falls.⁵⁸

Continue to: The medical and surgical histories

The medical and surgical histories are key pieces of information. The history of smoking, alcohol habits, and substance use is relevant.

A robust medication history is essential to evaluate a patient’s risk of falling. Polypharmacy—typically, defined as taking 4 or more medications—has been repeatedly associated with a heightened risk of falls.^53,59-61 Moreover, a dose-dependent association between polypharmacy and hospitalization following falls has been identified, and demonstrates that taking 10 or more medications greatly increases the risk of hospitalization.⁵⁹ Studies of polypharmacy cement the importance of inquiring about medication use when assessing imbalance, particularly in older patients.

Physical examination

A focused and detailed physical examination provides insight into systems that should be investigated:

• Obtain vital signs, including orthostatic vitals to test for orthostatic hypotension⁶²; keep in mind that symptoms of orthostatic dizziness can occur without orthostatic hypotension.
• Examine gait, which can distinguish between causes of imbalance (TABLE 2).^21,40,63-70
• Perform a cardiac examination.
• Assess visual acuity and visual fields; test for nystagmus and identify any optic-nerve and retinal abnormalities.
• Evaluate lower-limb sensation, proprioception, and motor function.
• Evaluate suspected vestibular dysfunction, including dysfunction with positional testing (the Dix-Hallpike maneuver⁷¹). The patient is taken from sitting to supine while the head is rotated 45° to the tested side by the examiner. As the patient moves into a supine position, the neck is extended 30° off the table and held for at least 30 seconds. The maneuver is positive if torsional nystagmus is noted while the head is held rotated during neck extension. The maneuver is negative if the patient reports dizziness, vertigo, unsteadiness, or “pressure in the head.” Torsional nystagmus must be present to confirm a diagnosis of benign paroxysmal positional vertigo.
• If you suspect a central nervous system cause of imbalance, assess the cranial nerves, coordination, strength, and, of course, balance.

CASE

Mr. J’s physical examination showed normal vital signs without significant postural changes in blood pressure. Gait analysis revealed a slowed gait, with reduced range of motion in both knees over the entire gait cycle. Audiometry revealed symmetric moderate sensorineural hearing loss characteristic of presbycusis.

Diagnostic investigations

Consider focused investigations into imbalance based on the history and physical examination. We discourage overly broad testing and imaging; in primary care, cost and limited access to technology can bar robust investigations into causes of imbalance. However, identification of acute pathologies should prompt immediate referral to the emergency department. Furthermore, specific symptoms (TABLE 1^7-56) should prompt referral to specialists for assessment.

Continue to: In the emergency department...

In the emergency department and academic hospitals, key investigations can identify causes of imbalance:

• Electrocardiography and Holter monitoring test for cardiac arrhythmias.
• Echocardiography identifies structural abnormalities.
• Radiography and computed tomography are useful for detecting musculoskeletal abnormalities.
• Bone densitometry can identify osteoporosis.
• Head and spinal cord magnetic resonance imaging can be used to identify lesions of the central nervous system.
• Computed tomographic angiography of the head and neck is useful for identifying stroke, cerebral atrophy, and stenotic lesions of the carotid and vertebral arteries.
• Nerve conduction studies and levels of serum vitamin B₁₂, hemoglobin A1C, thyroid-stimulating hormone, and random cortisol can uncover causes of peripheral neuropathy.
• Bedside cognitive screening tests can be used to measure cognitive decline.⁷²
• Suspicion of vestibular disease requires audiometry and vestibular testing, including videonystagmography, head impulse testing, and vestibular evoked myogenic potentials.

In many cases of imbalance, no specific underlying correctable cause is discovered.

Management of imbalance

Pharmacotherapy

Targeted pharmacotherapy can be utilized in select clinical scenarios:

• Medical treatment of peripheral neuropathy should target the underlying condition.
• Cognitive behavioral therapy and antidepressants are useful for treating anxiety and depressive disorders.⁷³
• Musculoskeletal pain can be managed with acetaminophen and topical nonsteroidal anti-inflammatory drugs (NSAIDs), using a short course of an oral NSAID when needed.⁷⁴
• Cardiovascular disease management might include any of several classes of pharmacotherapy, including antiplatelet and lipid-lowering medications, antiarrhythmic drugs, and antihypertensive agents.
• Acute episodes of vertigo due to vestibular neuritis or labyrinthitis can be managed with an antiemetic.⁴⁶

Surgical treatment

Surgery is infrequently considered for patients with imbalance. Examples of indications include microsurgical resection of vestibular schwannoma, resection of central nervous system tumors, lens replacement surgery for cataract, surgical management of severe spinal fracture, and hip or knee arthroplasty in select patients.

Tools for assessing the risk of falls

Scoring systems called falls risk assessment tools, or FRAT, have been developed to gauge a patient’s risk of falling. The various FRATs differ in specificity and sensitivity for predicting the risk of falls, and are typically designed for specific clinical environments, such as hospital inpatient care or long-term care facilities. Specifically, FRATs attempt to classify risk using sets of risk factors known to be associated with falls.

Continue to: Research abounds into...

In our experience, most patients with imbalance and who are at risk of falls do not have a detectable deficit of the vestibular system.

Research abounds into the validity of commonly used FRATs across institutions, patient populations, and clinical environments:

The Johns Hopkins FRAT^a determines risk using metrics such as age, fall history, incontinence, cognition, mobility, and medications⁷⁵; it is predominantly used for assessment in hospital inpatient units. This tool has been validated repeatedly.^76,77

Peninsula Health FRAT^b stratifies patients in subacute and residential aged-care settings, based on risk factors that include recent falls, medications, psychological status, and cognition.⁷⁸

FRAT-up^c is a web-based tool that generates falls risk using risk factors that users input. This tool has been studied in the context of patients older than 65 years living in the community.⁷⁹

Although FRATs are reasonably useful for predicting falls, their utility varies by patient population and clinical context. Moreover, it has been suggested that FRATs neglect environmental and personal factors when assessing risk by focusing primarily on bodily factors.⁸⁰ Implementing a FRAT requires extensive consideration of the target population and should be accompanied by clinical judgment that is grounded in an individual patient’s circumstances.⁸¹

Continue to: Preventing falls in primary care

An approach to preventing falls includes the development of individualized programs that account for frailty, a syndrome of physiologic decline associated with aging. Because frailty leads to diminished balance and mobility, a patient’s frailty index—determined using the 5 frailty phenotype criteria (exhaustion, weight loss, low physical activity, weakness, slowness)⁸² or the Canadian Study of Health and Aging Clinical Frailty Scale⁸³—is a useful tool for predicting falls risk and readmission for falls following trauma-related injury. Prevention of falls in communities is critical for reducing mortality and allowing older people to maintain their independence and quality of life.

Exercise. In some areas, exercise and falls prevention programs are accessible to seniors.⁸⁴ Community exercise programs that focus on balance retraining and muscle strengthening can reduce the risk of falls.^73,85 The Choosing Wisely initiative of the ABIM [American Board of Internal Medicine] Foundation recommends that exercise programs be designed around an accurate functional baseline of the patient to avoid underdosed strength training.⁵⁴

Multifactorial risk assessment in high-risk patients can reduce the rate of falls. Such an assessment includes examination of orthostatic blood pressure, vision and hearing, bone health, gait, activities of daily living, cognition, and environmental hazards, and enables provision of necessary interventions.^73,86 Hearing amplification, specifically, correlates with enhanced postural control, slowed cognitive decline, and a reduced likelihood of falls.^87-93 The mechanism behind improved balance performance might be reduced cognitive load through supporting a patient’s listening needs.^88-90

Pharmacotherapy. Optimizing medications and performing a complete medication review before prescribing new medications is highly recommended to avoid unnecessary polypharmacy^7,8,18,53-56 (TABLE 1^7-56).

Management of comorbidities associated with a higher risk of falls, including arthritis, cancer, stroke, diabetes, depression, kidney disease, chronic obstructive pulmonary disease, cognitive impairment, hypertension, and atrial fibrillation, is essential.^94-96

Continue to: Home safety interventions

Home safety interventions, through occupational therapy, are important. These include removing unsafe mats and step-overs and installing nonslip strips on stairs, ­double-sided tape under mats, and handrails.^73-97

Screening for risk of falls. The Centers for Disease Control and Prevention recommends that (1) all patients older than 65 years and (2) any patient presenting with an acute fall undergo screening for their risk of falls.⁹⁸ When a patient is identified as at risk of falling, you can, when appropriate, assess modifiable risk factors and facilitate interventions.⁹⁸ This strategy is supported by a 2018 statement from the US Preventive Services Task Force⁹⁹ that recommends identifying high-risk patients who have:

• a history of falling
• a balance disturbance that causes a deficit of mobility or function
• poor performance on clinical tests, such as the 3-meter Timed Up and Go (TUG) assessment (www.cdc.gov/steadi/pdf/TUG_test-print.pdf).

In addition to visual, proprioception, and vestibular dysfunction, cognitive and neurologic decline are also factors in imbalance.

An increased risk of falls should prompt you to refer the patient to community programs and physiotherapy in accordance with the individual’s personal goals⁹⁹; a balance and vestibular physiotherapist is ideally positioned to accurately assess and manage patients at risk of falls. Specifically, the Task Force identified exercise programs and multifactorial interventions as being beneficial in preventing falls in high-risk older people.⁹⁹

Balance assessment and rehabilitation in specialty centers

Polypharmacy— typically, defined as taking 4 or more medications— has been repeatedly associated with a heightened risk of falls.

An individualized rehabilitation program aims to restore safe mobility by testing and addressing specific balance deficits, improving functional balance, and increasing balance confidence. Collaboration with colleagues from physiotherapy and occupational therapy aids in tailoring individualized programs.

Many tests are available to assess balance, determine the risk of falls, and guide rehabilitation:

• The timed 10-meter walk test^d and the TUG test are simple assessments that measure functional mobility; both have normalized values for the risk of falls. A TUG time of ≥ 12 seconds suggests a high risk of falls.
• The 30-second chair stand^e evaluates functional lower-extremity strength in older patients. The test can indicate if lower-extremity strength is contributing to a patient’s imbalance.
• The modified clinical test of sensory interaction in balance^f is a static balance test that measures the integrity of sensory inputs. The test can suggest if 1 or more sensory systems are compromised.
• The mini balance evaluation systems test^g is similar: It can differentiate balance deficits by underlying system and allows individualization of a rehabilitation program.
• The functional gait assessment^h is a modification of the dynamic gait index that assesses postural stability during everyday dynamic activities, including tasks such as walking with head turns and pivots.
• The Berg Balance Scaleⁱ continues to be used extensively to assess balance.

Continue to: The mini balance evaluation systems test...

All patients older than 65 years and any patient presenting with an acute fall should undergo screening for their risk of falls.

The mini balance evaluation systems test, functional gait index, and Berg Balance Scale all have normative age-graded values to predict fall risk.

CASE

Mr. J was referred for balance assessment and to a rehabilitation program. He underwent balance physiotherapy, including multifactorial balance assessment, joined a community exercise program, was fitted with hearing aids, and had his home environment optimized by an occupational therapist. (See examples of “home safety interventions” under “Preventing falls in primary care.”)

Exercise programs should be designed around an accurate functional baseline of the patient to avoid underdosed strength training.

3 months later. Mr. J says he feels stronger on his feet. His knee pain has eased, and he is more confident walking around his home. He continues to engage in exercise programs and is comfortable running errands with his spouse.

CORRESPONDENCE
Jason A. Beyea, MD, PhD, FRCSC, Division of OtolaryngologyHead and Neck Surgery, Queen’s University, 144 Brock Street, Kingston, Ontario, Canada, K7L 5G2; jason.beyea@queensu.ca

^awww.hopkinsmedicine.org/institute_nursing/models_tools/jhfrat_acute%20care%20original_6_22_17.pdf

^bhttps://content.health.vic.gov.au/sites/default/files/migrated/files/collections/policies-and-guidelines/b/b2b_1a_frat_pdf.pdf

^cwww.ncbi.nlm.nih.gov/pmc/articles/PMC4376110/figure/figure14/?report=objectonly

^dwww.neuropt.org/docs/default-source/cpgs/core-outcome-measures/core-measure-10-meter-walk-test-(10mwt)_final.pdf?sfvrsn=c5585243_2&sfvrsn =c5585243_2

^ewww.cdc.gov/steadi/pdf/STEADI-Assessment-30Sec-508.pdf

^fwww.mdapp.co/mctsib-modified-clinical-test-of-sensory-interaction-in-balance-calculator-404/

^gwww.sralab.org/sites/default/files/2017-07/MiniBEST_revised_final_3_8_13.pdf

^hwww.neuropt.org/docs/default-source/cpgs/core-outcome-measures/function-gait-assessment-pocket-guide-proof9-(2).pdf?sfvrsn=b4f35043_0

ⁱwww.ncbi.nlm.nih.gov/books/NBK574518/

CASE Mr. J, a 75-year-old man, presents to your family practice reporting that he feels increasingly unsteady and slow while walking. He fell twice last year, without resulting injury. He now worries about tripping while walking around the house and relies on his spouse to run errands.

Almost 30% of people older than 65 years report 1 or more falls annually.

Clearly, Mr. J is experiencing a problem with balance. What management approach should you undertake to prevent him from falling?

Copyright Scott Bodell

Balance disorders are common in older people and drastically hinder quality of life.^1-4 Patients often describe imbalance as vague symptoms: dizziness, unsteadiness, faintness, spinning sensations.^5,6 Importantly, balance disorders disrupt normal gait and contribute to falls that are a major cause of disability and morbidity in older people. Almost 30% of people older than 65 years report 1 or more falls annually.⁷ Factors that increase the risk of falls include impaired mobility, previously reported falls, reduced psychological functioning, chronic medical conditions, and polypharmacy.^7,8

The cause of any single case of imbalance is often multifactorial, resulting from dysfunction of multiple body systems (TABLE 1^7-56); in our clinical experience, most patients with imbalance and who are at risk of falls do not have a detectable deficit of the vestibular system. These alterations in function arise in 3 key systems—vision, proprioception, and vestibular function—which signal to, and are incorporated by, the cerebellum to mediate balance. Cognitive and neurologic decline are also factors in imbalance.

Considering that 20% of falls result in serious injury in older populations, it is important to identify balance disorders and implement preventive strategies to mitigate harmful consequences of falls on patients’ health and independence.^7,57 In this article, we answer the question that the case presentation raises about the proper management approach to imbalance in family practice, including assessment of risk and rehabilitation strategies to reduce the risk of falls. Our insights and recommendations are based on our clinical experience and a review of the medical literature from the past 40 years.

CASE Mr. J has a history of hypertension, age-­related hearing loss, and osteoarthritis of the knees; he has not had surgery for the arthritis. His medications are antihypertensives and extra-strength acetaminophen for knee pain.

Making the diagnosis of a balance disorder

History

A thorough clinical history, often including a collateral history from caregivers, narrows the differential diagnosis. Information regarding onset, duration, timing, character, and previous episodes of imbalance is essential. Symptoms of imbalance are often challenging for the patient to describe: They might use terms such as vertigo or dizziness, when, in fact, on further questioning, they are describing balance difficulties. Inquiry into (1) their use of assistive walking devices and (2) development or exacerbation of neurologic, musculoskeletal, auditory, visual, and mood symptoms is necessary. Note the current level of their mobility, episodes of pain or fatigue, previous falls and associated injuries, fear of falling, balance confidence, and sensations that precede falls.⁵⁸

Continue to: The medical and surgical histories

The medical and surgical histories are key pieces of information. The history of smoking, alcohol habits, and substance use is relevant.

A robust medication history is essential to evaluate a patient’s risk of falling. Polypharmacy—typically, defined as taking 4 or more medications—has been repeatedly associated with a heightened risk of falls.^53,59-61 Moreover, a dose-dependent association between polypharmacy and hospitalization following falls has been identified, and demonstrates that taking 10 or more medications greatly increases the risk of hospitalization.⁵⁹ Studies of polypharmacy cement the importance of inquiring about medication use when assessing imbalance, particularly in older patients.

Physical examination

A focused and detailed physical examination provides insight into systems that should be investigated:

• Obtain vital signs, including orthostatic vitals to test for orthostatic hypotension⁶²; keep in mind that symptoms of orthostatic dizziness can occur without orthostatic hypotension.
• Examine gait, which can distinguish between causes of imbalance (TABLE 2).^21,40,63-70
• Perform a cardiac examination.
• Assess visual acuity and visual fields; test for nystagmus and identify any optic-nerve and retinal abnormalities.
• Evaluate lower-limb sensation, proprioception, and motor function.
• Evaluate suspected vestibular dysfunction, including dysfunction with positional testing (the Dix-Hallpike maneuver⁷¹). The patient is taken from sitting to supine while the head is rotated 45° to the tested side by the examiner. As the patient moves into a supine position, the neck is extended 30° off the table and held for at least 30 seconds. The maneuver is positive if torsional nystagmus is noted while the head is held rotated during neck extension. The maneuver is negative if the patient reports dizziness, vertigo, unsteadiness, or “pressure in the head.” Torsional nystagmus must be present to confirm a diagnosis of benign paroxysmal positional vertigo.
• If you suspect a central nervous system cause of imbalance, assess the cranial nerves, coordination, strength, and, of course, balance.

CASE

Mr. J’s physical examination showed normal vital signs without significant postural changes in blood pressure. Gait analysis revealed a slowed gait, with reduced range of motion in both knees over the entire gait cycle. Audiometry revealed symmetric moderate sensorineural hearing loss characteristic of presbycusis.

Diagnostic investigations

Consider focused investigations into imbalance based on the history and physical examination. We discourage overly broad testing and imaging; in primary care, cost and limited access to technology can bar robust investigations into causes of imbalance. However, identification of acute pathologies should prompt immediate referral to the emergency department. Furthermore, specific symptoms (TABLE 1^7-56) should prompt referral to specialists for assessment.

Continue to: In the emergency department...

In the emergency department and academic hospitals, key investigations can identify causes of imbalance:

• Electrocardiography and Holter monitoring test for cardiac arrhythmias.
• Echocardiography identifies structural abnormalities.
• Radiography and computed tomography are useful for detecting musculoskeletal abnormalities.
• Bone densitometry can identify osteoporosis.
• Head and spinal cord magnetic resonance imaging can be used to identify lesions of the central nervous system.
• Computed tomographic angiography of the head and neck is useful for identifying stroke, cerebral atrophy, and stenotic lesions of the carotid and vertebral arteries.
• Nerve conduction studies and levels of serum vitamin B₁₂, hemoglobin A1C, thyroid-stimulating hormone, and random cortisol can uncover causes of peripheral neuropathy.
• Bedside cognitive screening tests can be used to measure cognitive decline.⁷²
• Suspicion of vestibular disease requires audiometry and vestibular testing, including videonystagmography, head impulse testing, and vestibular evoked myogenic potentials.

In many cases of imbalance, no specific underlying correctable cause is discovered.

Management of imbalance

Pharmacotherapy

Targeted pharmacotherapy can be utilized in select clinical scenarios:

• Medical treatment of peripheral neuropathy should target the underlying condition.
• Cognitive behavioral therapy and antidepressants are useful for treating anxiety and depressive disorders.⁷³
• Musculoskeletal pain can be managed with acetaminophen and topical nonsteroidal anti-inflammatory drugs (NSAIDs), using a short course of an oral NSAID when needed.⁷⁴
• Cardiovascular disease management might include any of several classes of pharmacotherapy, including antiplatelet and lipid-lowering medications, antiarrhythmic drugs, and antihypertensive agents.
• Acute episodes of vertigo due to vestibular neuritis or labyrinthitis can be managed with an antiemetic.⁴⁶

Surgical treatment

Surgery is infrequently considered for patients with imbalance. Examples of indications include microsurgical resection of vestibular schwannoma, resection of central nervous system tumors, lens replacement surgery for cataract, surgical management of severe spinal fracture, and hip or knee arthroplasty in select patients.

Tools for assessing the risk of falls

Scoring systems called falls risk assessment tools, or FRAT, have been developed to gauge a patient’s risk of falling. The various FRATs differ in specificity and sensitivity for predicting the risk of falls, and are typically designed for specific clinical environments, such as hospital inpatient care or long-term care facilities. Specifically, FRATs attempt to classify risk using sets of risk factors known to be associated with falls.

Continue to: Research abounds into...

In our experience, most patients with imbalance and who are at risk of falls do not have a detectable deficit of the vestibular system.

Research abounds into the validity of commonly used FRATs across institutions, patient populations, and clinical environments:

The Johns Hopkins FRAT^a determines risk using metrics such as age, fall history, incontinence, cognition, mobility, and medications⁷⁵; it is predominantly used for assessment in hospital inpatient units. This tool has been validated repeatedly.^76,77

Peninsula Health FRAT^b stratifies patients in subacute and residential aged-care settings, based on risk factors that include recent falls, medications, psychological status, and cognition.⁷⁸

FRAT-up^c is a web-based tool that generates falls risk using risk factors that users input. This tool has been studied in the context of patients older than 65 years living in the community.⁷⁹

Although FRATs are reasonably useful for predicting falls, their utility varies by patient population and clinical context. Moreover, it has been suggested that FRATs neglect environmental and personal factors when assessing risk by focusing primarily on bodily factors.⁸⁰ Implementing a FRAT requires extensive consideration of the target population and should be accompanied by clinical judgment that is grounded in an individual patient’s circumstances.⁸¹

Continue to: Preventing falls in primary care

An approach to preventing falls includes the development of individualized programs that account for frailty, a syndrome of physiologic decline associated with aging. Because frailty leads to diminished balance and mobility, a patient’s frailty index—determined using the 5 frailty phenotype criteria (exhaustion, weight loss, low physical activity, weakness, slowness)⁸² or the Canadian Study of Health and Aging Clinical Frailty Scale⁸³—is a useful tool for predicting falls risk and readmission for falls following trauma-related injury. Prevention of falls in communities is critical for reducing mortality and allowing older people to maintain their independence and quality of life.

Exercise. In some areas, exercise and falls prevention programs are accessible to seniors.⁸⁴ Community exercise programs that focus on balance retraining and muscle strengthening can reduce the risk of falls.^73,85 The Choosing Wisely initiative of the ABIM [American Board of Internal Medicine] Foundation recommends that exercise programs be designed around an accurate functional baseline of the patient to avoid underdosed strength training.⁵⁴

Multifactorial risk assessment in high-risk patients can reduce the rate of falls. Such an assessment includes examination of orthostatic blood pressure, vision and hearing, bone health, gait, activities of daily living, cognition, and environmental hazards, and enables provision of necessary interventions.^73,86 Hearing amplification, specifically, correlates with enhanced postural control, slowed cognitive decline, and a reduced likelihood of falls.^87-93 The mechanism behind improved balance performance might be reduced cognitive load through supporting a patient’s listening needs.^88-90

Pharmacotherapy. Optimizing medications and performing a complete medication review before prescribing new medications is highly recommended to avoid unnecessary polypharmacy^7,8,18,53-56 (TABLE 1^7-56).

Management of comorbidities associated with a higher risk of falls, including arthritis, cancer, stroke, diabetes, depression, kidney disease, chronic obstructive pulmonary disease, cognitive impairment, hypertension, and atrial fibrillation, is essential.^94-96

Continue to: Home safety interventions

Home safety interventions, through occupational therapy, are important. These include removing unsafe mats and step-overs and installing nonslip strips on stairs, ­double-sided tape under mats, and handrails.^73-97

Screening for risk of falls. The Centers for Disease Control and Prevention recommends that (1) all patients older than 65 years and (2) any patient presenting with an acute fall undergo screening for their risk of falls.⁹⁸ When a patient is identified as at risk of falling, you can, when appropriate, assess modifiable risk factors and facilitate interventions.⁹⁸ This strategy is supported by a 2018 statement from the US Preventive Services Task Force⁹⁹ that recommends identifying high-risk patients who have:

• a history of falling
• a balance disturbance that causes a deficit of mobility or function
• poor performance on clinical tests, such as the 3-meter Timed Up and Go (TUG) assessment (www.cdc.gov/steadi/pdf/TUG_test-print.pdf).

In addition to visual, proprioception, and vestibular dysfunction, cognitive and neurologic decline are also factors in imbalance.

An increased risk of falls should prompt you to refer the patient to community programs and physiotherapy in accordance with the individual’s personal goals⁹⁹; a balance and vestibular physiotherapist is ideally positioned to accurately assess and manage patients at risk of falls. Specifically, the Task Force identified exercise programs and multifactorial interventions as being beneficial in preventing falls in high-risk older people.⁹⁹

Balance assessment and rehabilitation in specialty centers

Polypharmacy— typically, defined as taking 4 or more medications— has been repeatedly associated with a heightened risk of falls.

An individualized rehabilitation program aims to restore safe mobility by testing and addressing specific balance deficits, improving functional balance, and increasing balance confidence. Collaboration with colleagues from physiotherapy and occupational therapy aids in tailoring individualized programs.

Many tests are available to assess balance, determine the risk of falls, and guide rehabilitation:

• The timed 10-meter walk test^d and the TUG test are simple assessments that measure functional mobility; both have normalized values for the risk of falls. A TUG time of ≥ 12 seconds suggests a high risk of falls.
• The 30-second chair stand^e evaluates functional lower-extremity strength in older patients. The test can indicate if lower-extremity strength is contributing to a patient’s imbalance.
• The modified clinical test of sensory interaction in balance^f is a static balance test that measures the integrity of sensory inputs. The test can suggest if 1 or more sensory systems are compromised.
• The mini balance evaluation systems test^g is similar: It can differentiate balance deficits by underlying system and allows individualization of a rehabilitation program.
• The functional gait assessment^h is a modification of the dynamic gait index that assesses postural stability during everyday dynamic activities, including tasks such as walking with head turns and pivots.
• The Berg Balance Scaleⁱ continues to be used extensively to assess balance.

Continue to: The mini balance evaluation systems test...

All patients older than 65 years and any patient presenting with an acute fall should undergo screening for their risk of falls.

The mini balance evaluation systems test, functional gait index, and Berg Balance Scale all have normative age-graded values to predict fall risk.

CASE

Mr. J was referred for balance assessment and to a rehabilitation program. He underwent balance physiotherapy, including multifactorial balance assessment, joined a community exercise program, was fitted with hearing aids, and had his home environment optimized by an occupational therapist. (See examples of “home safety interventions” under “Preventing falls in primary care.”)

Exercise programs should be designed around an accurate functional baseline of the patient to avoid underdosed strength training.

3 months later. Mr. J says he feels stronger on his feet. His knee pain has eased, and he is more confident walking around his home. He continues to engage in exercise programs and is comfortable running errands with his spouse.

CORRESPONDENCE
Jason A. Beyea, MD, PhD, FRCSC, Division of OtolaryngologyHead and Neck Surgery, Queen’s University, 144 Brock Street, Kingston, Ontario, Canada, K7L 5G2; jason.beyea@queensu.ca

^awww.hopkinsmedicine.org/institute_nursing/models_tools/jhfrat_acute%20care%20original_6_22_17.pdf

^bhttps://content.health.vic.gov.au/sites/default/files/migrated/files/collections/policies-and-guidelines/b/b2b_1a_frat_pdf.pdf

^cwww.ncbi.nlm.nih.gov/pmc/articles/PMC4376110/figure/figure14/?report=objectonly

^dwww.neuropt.org/docs/default-source/cpgs/core-outcome-measures/core-measure-10-meter-walk-test-(10mwt)_final.pdf?sfvrsn=c5585243_2&sfvrsn =c5585243_2

^ewww.cdc.gov/steadi/pdf/STEADI-Assessment-30Sec-508.pdf

^fwww.mdapp.co/mctsib-modified-clinical-test-of-sensory-interaction-in-balance-calculator-404/

^gwww.sralab.org/sites/default/files/2017-07/MiniBEST_revised_final_3_8_13.pdf

^hwww.neuropt.org/docs/default-source/cpgs/core-outcome-measures/function-gait-assessment-pocket-guide-proof9-(2).pdf?sfvrsn=b4f35043_0

ⁱwww.ncbi.nlm.nih.gov/books/NBK574518/

Dermoscopic findings were consistent with a melanocytic lesion and a scoop shave biopsy revealed a 2.7 mm thick nodular melanoma.

Melanoma is the most lethal skin cancer in the United States. The likelihood of metastatic spread to lymph nodes statistically increases beyond a probability of 5% when patients have primary lesions thicker than 0.8 mm.¹ Thus, for patients with tumors thicker than 0.8 mm, or some other high-risk features such as high mitotic index, a sentinel lymph node biopsy (SLNB) is recommended. This patient underwent wide local excision and reconstruction of his ear. An SLNB was also performed and the results were negative.

The patient returned for a complete skin exam every 3 months. Ten months after the excision, he presented with episodes of headache and confusion. Magnetic resonance imaging revealed metastasis to the brain; a biopsy confirmed that it was melanoma. Two months later, after attempts at resection of the brain metastasis, the patient died.

This case demonstrates that patients with thick melanoma are at continued risk for recurrence and poor outcomes; they benefit from close surveillance and work-up of unusual symptoms that might suggest metastases. Phase 3 trials are currently underway to consider the use of adjuvant therapy in patients with advanced stage II melanoma who, on average, have worse outcomes than patients with early-stage III disease.²

‌

Text courtesy of Jonathan Karnes, MD, medical director, MDFMR Dermatology Services, Augusta, ME. Photos courtesy of Jonathan Karnes, MD (copyright retained).

Dermoscopic findings were consistent with a melanocytic lesion and a scoop shave biopsy revealed a 2.7 mm thick nodular melanoma.

Melanoma is the most lethal skin cancer in the United States. The likelihood of metastatic spread to lymph nodes statistically increases beyond a probability of 5% when patients have primary lesions thicker than 0.8 mm.¹ Thus, for patients with tumors thicker than 0.8 mm, or some other high-risk features such as high mitotic index, a sentinel lymph node biopsy (SLNB) is recommended. This patient underwent wide local excision and reconstruction of his ear. An SLNB was also performed and the results were negative.

The patient returned for a complete skin exam every 3 months. Ten months after the excision, he presented with episodes of headache and confusion. Magnetic resonance imaging revealed metastasis to the brain; a biopsy confirmed that it was melanoma. Two months later, after attempts at resection of the brain metastasis, the patient died.

This case demonstrates that patients with thick melanoma are at continued risk for recurrence and poor outcomes; they benefit from close surveillance and work-up of unusual symptoms that might suggest metastases. Phase 3 trials are currently underway to consider the use of adjuvant therapy in patients with advanced stage II melanoma who, on average, have worse outcomes than patients with early-stage III disease.²

‌

Text courtesy of Jonathan Karnes, MD, medical director, MDFMR Dermatology Services, Augusta, ME. Photos courtesy of Jonathan Karnes, MD (copyright retained).

Dermoscopic findings were consistent with a melanocytic lesion and a scoop shave biopsy revealed a 2.7 mm thick nodular melanoma.

Melanoma is the most lethal skin cancer in the United States. The likelihood of metastatic spread to lymph nodes statistically increases beyond a probability of 5% when patients have primary lesions thicker than 0.8 mm.¹ Thus, for patients with tumors thicker than 0.8 mm, or some other high-risk features such as high mitotic index, a sentinel lymph node biopsy (SLNB) is recommended. This patient underwent wide local excision and reconstruction of his ear. An SLNB was also performed and the results were negative.

The patient returned for a complete skin exam every 3 months. Ten months after the excision, he presented with episodes of headache and confusion. Magnetic resonance imaging revealed metastasis to the brain; a biopsy confirmed that it was melanoma. Two months later, after attempts at resection of the brain metastasis, the patient died.

This case demonstrates that patients with thick melanoma are at continued risk for recurrence and poor outcomes; they benefit from close surveillance and work-up of unusual symptoms that might suggest metastases. Phase 3 trials are currently underway to consider the use of adjuvant therapy in patients with advanced stage II melanoma who, on average, have worse outcomes than patients with early-stage III disease.²

‌

Text courtesy of Jonathan Karnes, MD, medical director, MDFMR Dermatology Services, Augusta, ME. Photos courtesy of Jonathan Karnes, MD (copyright retained).

This supplement will teach you about the 6 pillars of Lifestyle Medicine, looks at the future of Lifestyle Medicine, demonstrates the power of Lifestyle Medicine as evidence-based treatment of chronic disease, and describes how you can incorporate Lifestyle Medicine into your practice.

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This supplement will teach you about the 6 pillars of Lifestyle Medicine, looks at the future of Lifestyle Medicine, demonstrates the power of Lifestyle Medicine as evidence-based treatment of chronic disease, and describes how you can incorporate Lifestyle Medicine into your practice.

Click here to access this content now 

This supplement will teach you about the 6 pillars of Lifestyle Medicine, looks at the future of Lifestyle Medicine, demonstrates the power of Lifestyle Medicine as evidence-based treatment of chronic disease, and describes how you can incorporate Lifestyle Medicine into your practice.

Click here to access this content now 

Physical exam revealed a plaque with multiple verrucous projections and clusters of smaller circular papules, all with associated thrombosed vessels. The plaque interrupted normal skin lines, consistent with a large, benign, plantar wart, also termed a mosaic wart when clusters of individual plantar warts form a single plaque.

Mosaic warts are caused by infection with human papillomavirus (HPV). They begin as individual papules or macules with a rough surface and small pinpoint capillaries. Plantar warts can be painful if located over a weight-bearing area of the foot. Plantar warts spread by autoinoculation from microtrauma to the foot. Picking at the wart, having it rub against a shoe insert, or exposing it to contaminated surfaces (such as a shower floor) can lead to the wart’s spread. Usually, the diagnosis of a plantar wart is based on clinical examination, with the main differential including a corn or callus. However, rare instances of squamous cell carcinoma or arsenical keratoses can mimic a plantar wart.

Although plantar warts can resolve spontaneously over months or years, patients often seek treatment. Warts may require multiple treatments and various therapies. Common first-line therapies include over-the-counter (OTC) salicylic acid and cryotherapy. The list of other therapies is lengthy, with no single agent credited with high cure rates in well-controlled trials. These therapies include intralesional candida antigen, topical 5 fluorouracil, and topical imiquimod, among many others.

Salicylic acid is available in several forms including 40% acid pads that may be cut to size and applied daily to affected areas. These pads may need to be reinforced with tape to improve adherence. Salicylic acid is also available as a 17% paint-on formulation that can be applied daily, with or without occlusion. This treatment usually requires 2 to 3 months of daily application.

When treated in the office, cryotherapy with liquid nitrogen (LN2) is a first-line therapy, with a cure rate of approximately 65%—similar to that of OTC salicylic acid.¹ Application of LN2 via a spray cannister every 2 to 4 weeks until clear is a common strategy. Freezing the area, letting it thaw, and repeating the freeze again in 1 sitting improves clearance. Pain from LN2 can be significant and not all patients can tolerate it. However, for a motivated patient, this can be more convenient than home treatments or a good option when home treatment has failed.

This patient chose cryotherapy, and his foot cleared completely after several rounds of in-office treatments.

‌

Text courtesy of Jonathan Karnes, MD, medical director, MDFMR Dermatology Services, Augusta, ME. Photos courtesy of Jonathan Karnes, MD (copyright retained).

Physical exam revealed a plaque with multiple verrucous projections and clusters of smaller circular papules, all with associated thrombosed vessels. The plaque interrupted normal skin lines, consistent with a large, benign, plantar wart, also termed a mosaic wart when clusters of individual plantar warts form a single plaque.

Mosaic warts are caused by infection with human papillomavirus (HPV). They begin as individual papules or macules with a rough surface and small pinpoint capillaries. Plantar warts can be painful if located over a weight-bearing area of the foot. Plantar warts spread by autoinoculation from microtrauma to the foot. Picking at the wart, having it rub against a shoe insert, or exposing it to contaminated surfaces (such as a shower floor) can lead to the wart’s spread. Usually, the diagnosis of a plantar wart is based on clinical examination, with the main differential including a corn or callus. However, rare instances of squamous cell carcinoma or arsenical keratoses can mimic a plantar wart.

Although plantar warts can resolve spontaneously over months or years, patients often seek treatment. Warts may require multiple treatments and various therapies. Common first-line therapies include over-the-counter (OTC) salicylic acid and cryotherapy. The list of other therapies is lengthy, with no single agent credited with high cure rates in well-controlled trials. These therapies include intralesional candida antigen, topical 5 fluorouracil, and topical imiquimod, among many others.

Salicylic acid is available in several forms including 40% acid pads that may be cut to size and applied daily to affected areas. These pads may need to be reinforced with tape to improve adherence. Salicylic acid is also available as a 17% paint-on formulation that can be applied daily, with or without occlusion. This treatment usually requires 2 to 3 months of daily application.

When treated in the office, cryotherapy with liquid nitrogen (LN2) is a first-line therapy, with a cure rate of approximately 65%—similar to that of OTC salicylic acid.¹ Application of LN2 via a spray cannister every 2 to 4 weeks until clear is a common strategy. Freezing the area, letting it thaw, and repeating the freeze again in 1 sitting improves clearance. Pain from LN2 can be significant and not all patients can tolerate it. However, for a motivated patient, this can be more convenient than home treatments or a good option when home treatment has failed.

This patient chose cryotherapy, and his foot cleared completely after several rounds of in-office treatments.

‌

Text courtesy of Jonathan Karnes, MD, medical director, MDFMR Dermatology Services, Augusta, ME. Photos courtesy of Jonathan Karnes, MD (copyright retained).

Physical exam revealed a plaque with multiple verrucous projections and clusters of smaller circular papules, all with associated thrombosed vessels. The plaque interrupted normal skin lines, consistent with a large, benign, plantar wart, also termed a mosaic wart when clusters of individual plantar warts form a single plaque.

Mosaic warts are caused by infection with human papillomavirus (HPV). They begin as individual papules or macules with a rough surface and small pinpoint capillaries. Plantar warts can be painful if located over a weight-bearing area of the foot. Plantar warts spread by autoinoculation from microtrauma to the foot. Picking at the wart, having it rub against a shoe insert, or exposing it to contaminated surfaces (such as a shower floor) can lead to the wart’s spread. Usually, the diagnosis of a plantar wart is based on clinical examination, with the main differential including a corn or callus. However, rare instances of squamous cell carcinoma or arsenical keratoses can mimic a plantar wart.

Although plantar warts can resolve spontaneously over months or years, patients often seek treatment. Warts may require multiple treatments and various therapies. Common first-line therapies include over-the-counter (OTC) salicylic acid and cryotherapy. The list of other therapies is lengthy, with no single agent credited with high cure rates in well-controlled trials. These therapies include intralesional candida antigen, topical 5 fluorouracil, and topical imiquimod, among many others.

Salicylic acid is available in several forms including 40% acid pads that may be cut to size and applied daily to affected areas. These pads may need to be reinforced with tape to improve adherence. Salicylic acid is also available as a 17% paint-on formulation that can be applied daily, with or without occlusion. This treatment usually requires 2 to 3 months of daily application.

When treated in the office, cryotherapy with liquid nitrogen (LN2) is a first-line therapy, with a cure rate of approximately 65%—similar to that of OTC salicylic acid.¹ Application of LN2 via a spray cannister every 2 to 4 weeks until clear is a common strategy. Freezing the area, letting it thaw, and repeating the freeze again in 1 sitting improves clearance. Pain from LN2 can be significant and not all patients can tolerate it. However, for a motivated patient, this can be more convenient than home treatments or a good option when home treatment has failed.

This patient chose cryotherapy, and his foot cleared completely after several rounds of in-office treatments.

‌

Text courtesy of Jonathan Karnes, MD, medical director, MDFMR Dermatology Services, Augusta, ME. Photos courtesy of Jonathan Karnes, MD (copyright retained).

A shave biopsy (performed carefully to avoid caustic hemostatic agents irritating the conjunctiva) confirmed the diagnosis of a micronodular basal cell carcinoma (BCC).

BCC is a common tumor occurring on the eyelids and in the periocular region. Any new growing papule on the eyelids, history of focal bleeding, irritation, or focal loss of eyelashes should cause suspicion for BCC. Patients are often unaware of any symptoms when lesions begin, highlighting the importance of close inspection of the eyelids when skin or eye exams are performed. The differential diagnosis includes benign lesions such as hidrocystomas and nevi, as well as malignancies, including sebaceous carcinoma and squamous cell carcinoma.¹

Factors that come into play when exploring eyelid BCC treatment options include tumor removal, eyelid function, and appearance. The potential morbidity associated with tumor spread in the periorbital region highlights the importance of early detection of eyelid cancers. Mohs micrographic surgery (MMS) is a first choice for tumor removal of an eyelid BCC and offers a high cure rate with minimal tissue removal.

Removal of an eyelid BCC may be a multidisciplinary endeavor with MMS achieving a clear margin, and Ophthalmology or Oculoplastics following with repair and closure soon after. Patients who can’t tolerate surgery should consider vismodegib, a targeted chemotherapy, or radiotherapy.

The patient in this case opted for a single staged excision and repair with Oculoplastics and has had no recurrence. He subsequently underwent a revision procedure to improve ectropion.

‌

Text courtesy of Jonathan Karnes, MD, medical director, MDFMR Dermatology Services, Augusta, ME. Photos courtesy of Jonathan Karnes, MD (copyright retained).