One minute, I was trotting peacefully along a rutted hillside path. The next, I lay in a heap on my left side, so wracked with pain it was hard to breathe. A longtime runner, I traded pavement for trails a couple years ago, and since then I've taken a few tumbles. But never had I fallen so fast and so hard. Moaning, I inventoried what might be broken.
Then panic set in as I considered some horrifying statistics: An estimated one in three women will break a hip, and, for patients older than 60, the one-year mortality rate after a hip fracture can be as high as 58 percent. Though still in my early 50s, I thought of hardy patients I'd cared for over the years who had swiftly declined after one bad fall.
I was lucky. I had no major fractures or head trauma, and my bones, on X-ray, seemed reasonably strong. But I hobbled around for weeks, my left side turning from purple to yellow, my arm in a sling. Once I was finally back on the trail, I could not shake the fear that my next fall (and there certainly would be one) could be far worse. This anxiety quickly extended to any sport involving a hard surface, including street jogging, cycling, skating, and skiing. I was suffering from a well-described "syndrome": fear of falling or FOF, which is especially common in the over-50 crowd. Research shows that people with FOF, regardless of whether they have experienced a bad fall, are more likely to become deconditioned, depressed and socially isolated.
At this point, my options seemed clear: confine all sports to a squishy mat, or learn how to fall safely. But what is the best way to fall, and how do we master this?
I often discuss fall prevention with my older patients, but I feel unequipped to tell them how to fall well. A PubMed search unearthed hundreds of studies evaluating exercise programs, assistive devices and physical environment modifications (shower bars, handrails, rug pads, etc.) to keep people from taking a spill. But there has been very little research about the safest way to fall. One synthesis of 13 small studies (mostly performed on young athletes) suggests that going into a squat when falling backward, flexing elbows when pitching forward, and rolling over one shoulder if headed sideways are all good strategies. But the article gave little information about how to put this information into practice or whether these strategies work if you are no longer in your 20s.
I decided to seek out some experts in the art (and science) of falling safely.
On YouTube, I discovered Stephen Jepson, 77, a retired ceramics professor who teaches people how to stay nimble and upright or, should gravity prevail, how to avoid getting hurt. In one video, he runs around doing all sorts of tricks, including tightrope walking and jumping hurdles. Jepson says the key to avoiding fall injuries is to maintain quick hands and feet by constantly learning new physical skills. At 73, he taught himself to juggle clubs while standing on a balancing board, and, recently, he mastered the one-wheel hoverboard (imagine a skateboard with one large wheel in the middle). For me, he suggested these steps:
Level 1. Balance on one foot. Start by doing it near a doorway or chair so there is something to grab for support.
Level 2. Use your non-dominant hand to stir a pot.
Level 3. Use your non-dominant hand to stir a pot while standing on one foot.
Unsurprisingly, Jepson does his share of falling. "If you are going to fall, the best way to do it is to bend a knee and roll at an angle over one shoulder to protect your hip and your noggin," he said.
Next, I contacted a doctor whose patients fall for a living. Ken Akizuki, team orthopedist for the San Francisco Giants, describes sliding into a base as a form of controlled falling. Akizuki can easily list players who fall well and those who don't. Pitcher Madison Bumgarner is "incredibly athletic," he said, while with onetime pitcher Shawn Estes, "you just watched and hoped he didn't get hurt."
Akizuki echoed Jepson's advice about the best falling technique: "Tuck your head, use your strength to direct your fall, and roll so that you take most of the impact on your backside, the upper back and/or gluts being the most resistant parts of your body."
Akizuki said that, rather than keeping me safe, my newfound fear of falling could increase my chances of injury. "[S]he who hesitates gets hurt," he cautioned, and recommended I learn aikido to master this falling business.
I signed up for an introductory aikido class. The sensei, a powerful-looking, 50-something woman, explained that this Japanese martial art is about not fighting but converting violent movements from an aggressor into something that is safe and harmonious. After learning to bow and stand, we moved on to ukemi - or the "art of falling." I began to sweat as I watched her effortlessly tuck one leg under, become a human ball, and roll backward or forward unharmed. I looked around and noticed that some of my youngish classmates seemed to share my terror. Apparently FOF is not necessarily an age-related thing. I took a deep breath and threw myself earthward, glad that there was a thick mat to protect me from my mistakes.
After class, I called Adam Tenforde, sports medicine doctor and assistant professor at Harvard Medical School. Although he studies the biomechanics of running and how to avoid falling, he was open to discussing the art (and science) of falling safely.
Tenforde described how his young children naturally explored their surroundings, using fingers and toes with equal dexterity and moving from upright to rolling and back again.
He thinks we quickly lose this ease because almost everything in our lives, including chairs, desks, beds, cars and even cushioned shoes, is designed to create distance between us and the ground. He recommends we counteract this, especially with our footwear: He and his kids go barefoot around the house and wear "minimal" shoes with thin, flexible soles for both sports and everyday living.
According to Tenforde, information we get from the bottoms of our feet (the technical term is plantar neurosensory input) helps us maintain balance. This input, coupled with muscle strength and agility, is essential for generating a "good correctional movement" should we fall. He refers his fall-prone patients to physical therapists who take an integrated, whole-body approach to rehabilitation and don't focus on just a couple of muscle groups. "It's about the whole kinetic chain," he said.
During my conversation with Tenforde, I realized that the same skills that keep me upright could also make me a better faller. Maybe it was not just luck that protected me from major injury that day on the trail! Maybe all that mud sliding and rock hopping over the past couple years had trained me to tumble well. Immediately, my FOF begin to disappear.
The next day, I put on shoes with paper-thin soles and hit the trail. While studies of how these shoes affect balance are contradictory, I appreciated how they improved my gait and made me feel more grounded. (Note: the transition to minimal shoes should be gradual to avoid injury.) Gone was that feeling of impending doom. I welcomed the uneven terrain and slippery stream crossings as a chance to build stability and fall resilience.
I had asked Tenforde if there is a specific age after which he advises patients to stop having an active lifestyle. He answers: "I take your age and subtract it from 100, whatever number I get is the number of years I'm going to help you keep doing what you love to do." In my case, that's 47. So, I will continue to practice ukemi and stir my soup with my left hand while standing on one foot. And once I master this, I'll try learning some new tricks.
Miller is a family physician and author of "Farmacology" and "The Jungle Effect.
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