A Physician’s Calling “Falls” Into Place
By Margie Pensak
Dr. Levan (Levi) Atanelov is somewhat of an anomaly. How many USSR natives do you know who became baalei teshuvah, learned in Yeshivas Mir, graduated medical school and left a Johns Hopkins Hospital clinical practice to open the first comprehensive fall prevention medical institute in the U.S., running it while learning in kollel half-a-day?
Inyan had the pleasure of speaking with Dr. Atanelov, the Founder/CEO of Steady Strides, which utilizes a “whole-person approach” to provide comprehensive medical and rehabilitation care, and with Aidel Cooperman, OTR/L, his Rehab director, to learn how they have helped patients of all ages prevent potentially disastrous falls.
Dr. Atanelov, please tell us a bit about your background.
I was born in Tbilisi, Georgia (USSR at that time), and came to Los Angeles in 1995. After finishing public high school and UCLA for a bachelor’s in cybernetics and a master’s in biochemistry, I became a baal teshuvah and attended Machon Shlomo, followed by Yeshivas Mir, Yerushalayim. When I returned to the States, I went to medical school in San Diego and then moved to Baltimore for a shomer Shabbos residency at Johns Hopkins Hospital. After completing my residency, I was recruited there to stay on to train other residents. I was later offered the position of Assistant Residency Program Director and advanced to Assistant Professor rank. I am married with three amazing kids.
What type of medicine do you specialize in?
My specialty is physiatry. A physiatrist is, more simply, a mixture of orthopedics and neurology. We handle the decision-making function and the executive function. We treat patients with peripheral neuropathy, vestibular disorders, stroke, amputation, Parkinson’s Disease, spinal stenosis, pain, or weakness — conditions which can impair balance and/or cause gait deficits that contribute to fall risk. We see patients who have had prior falls, and those who have not fallen but want to prevent future falls.
Did going to yeshiva influence you to enter that specialty?
Before learning at the Mir in Yerushalayim, I attended Machon Shlomo. There, I learned a little bit about medical ethics and how important it is to do the right thing. When I came to Hopkins for my residency training, we heard a talk by Dr. Peter Pronovost, the world’s No. 1 expert on medical quality and improvement. The fact that someone was talking about this topic struck a chord with me. While doing my residency, there was a chance for me to do a year fellowship with him and his group. I was very excited about it. During this time, I discovered that there was no practical textbook written on the topic — so I wrote one: Resident’s Handbook of Medical Quality and Safety.
What were the stepping stones that led to opening your unique medical institute?
It was obviously hashgachah! Because I was interested in medical quality and fall prevention as part of quality care during my career at Hopkins, the idea of preventing falls in older adults kind-of fell into my lap. (Pun intended!) I was told to do something “Hopkins-like” — to do something that no one knows how to do and become the No. 1 specialist in the world in it.
Falls in older adults are the No. 1 cause of preventable death in this patient population but unfortunately physicians don’t have an effective and efficient approach to solve this problem. Fall prevention is not something that you do to make a lot of money — it’s something you do because you want to help people. I chose to tackle it.
While working on the project, I became the medical director of the Johns Hopkins University School of Medicine (JHUSM) Department of Physical Medicine and Rehabilitation Fall Prevention Clinic. Later on, I decided to leave Hopkins and start a private clinic specializing in fall prevention and stroke rehabilitation, enabling me to have more flexibility and independence to learn in kollel. Two years ago, I started learning in kollel at Yeshivas Ner Yisrael for the morning seder.
Tell us more about your work.
After some time, I realized that what everyone else was doing just didn’t work. Hashem gave me a couple ideas. I thought, what would I do if it were up to me — alone — if insurance payments and all other obstacles were not a consideration. How would I help my grandmother now? I would get piles of medical files on my patients at Hopkins, which were not helpful. It’s not like it is a one-size-fits-all; there are multiple things which can cause falls.
Typically, how long do patients undergo treatment?
My gait and balance rehabilitation program lasts 6-12 weeks on average. It includes medical work up and management as needed, together with physical and/or occupational therapy as needed.
What are some of the most common causes of falls?
Somebody can have a stroke and fall or have a bad knee. Some can have neuropathy or have an amputation. You really need about five doctors who will examine the patient, all at once, and confer with one another. They also must know the patient’s background regarding what worked and what didn’t work, in addition to knowing rehab medicine. All these steps are usually missing. Typically, someone makes an appointment to see a primary care doctor and a specialist. Then, they wait six months to see the next specialist. Then they fall and go to the hospital. The primary care physician does not have the clinical acumen to coordinate a plan of care; they are not trained to diagnose this type of complex question. So, the patient will end up seeing several specialists, not realizing that nothing is happening because these doctors are not trained to prioritize the many comorbid diagnoses to identify the primary one responsible for the falls. Our approach is to have one fall prevention specialist physician act like a one-stop shop to help identify and prioritize the different issues contributing to fall risk.
How many seniors fall each year?
Roughly, a third to a fourth of all seniors fall every year. Twenty percent of falls are traumatic falls — they lead to brain injury, a broken hip, sometimes death. If someone comes to me and they are having a fall every other month, of the six falls per year, one may be traumatic. Let’s say I can get them 50% better, they go from 6 falls to 3 falls a year. That means that in a year, they will probably not have a traumatic fall. That’s a big change.
How do you help your patients minimize their falls?
You cannot undo the damage that a patient has. For example, if they have neuropathy, I can’t help them sprout new nerves, or if they have spinal stenosis and have bad connections going from the feet to the brain, I can’t undo the damage. What I can do, however, is use neuroplasticity. This is, basically, a rewiring of the brain so the brain gets less information, but still does a better job than it was doing before, by teaching it shortcuts for balance issues. This has been successful even for patients with memory deficits. In addition to tailor-made classical balance exercises, we use visual imagery, music and dance therapy to engage the limbic system of the brain which controls key emotions and memories. We aim for a “whole brain” learning protocol, to include the frontal lobes controlling visual attention, abstract thinking and judgment; the brain stem, which controls automatic behaviors; and the limbic system, which controls the emotions.
What are some of the myths about falling?
Myth No. 1 is there is nothing that can be done about falls. That is a mistake. The reason people think this is because they went to physical therapy, and it didn’t work sufficiently. Just PT, alone, will not work. Another myth is that falling is a normal part of growing old. A third myth is that there is nothing that can be done to help someone who suffers from dementia to minimize falling.
Will improving strength improve balance and prevent falling?
That is another myth. Weakness is rarely a cause of the issue for losing balance. It is often comorbid, but not the thing that is causing the trouble; it’s a tertiary problem. Yet another myth is : ‘I am going to walk and get better.’ Walking is good for heart and brain health but will not make your balance get better by itself.
How can you tell if you have a balance problem?
Poor balance is the most common cause of falls. Something you can do at home — with a responsible person next to you — is try to stand on one foot without holding on to anybody or anything. The data shows that someone who can’t stand five seconds or less, has double the risk of falls and fractures compared to someone who can stand for 20 seconds or more. Having good vision is very helpful for navigating the environment, and having good sustained visual attention is important. People who have issues with vision, depression or anxiety are prevented from having good balance. Depression causes psychomotor retardation and likely impaired sustained attention, contributing to fall risk because people with poor balance end up relying on visual cues, which need good sustained visual attention.
[The next two questions were addressed to Mrs. Aidel Cooperman, OT, the director of Rehab at Steady Strides.]
Can you please share some success stories with our readers?
Sure. A 50-year-old police detective had a stroke which weakened his left side. He experienced disturbing sensations (tingling, numbness, tightness) from his left jaw all the way to his feet. We worked to normalize his sensations using a variety of modalities. By the end of treatment, he was not bothered by sensations and was able to kneel, shoot a gun, ride a motorcycle and return to work.
Another patient, a 64-year-old male teacher, was diagnosed with Parkinson’s. He walked with a shuffling gait, and stiff upper body, with limited arm movement. He did tai chi consistently for upper and lower body integration and worked on his balance with a specialized board. By the end of treatment, he was able to do 18 tai chi movements effortlessly on the balance board, without any loss of balance.
These are great stories, Mrs. Cooperman. Do you have others to share?
We also helped a 75-year-old active man who was depressed due to falling while jogging, one of his favorite activities. We discovered that his bifocals were ill-prescribed and causing visual distortion when he jogged. He was also distracting himself with changing the channel on his iPod as he jogged. On top of that, he was not drinking enough water, becoming thirsty mid-run. At the end of treatment, he was back to jogging two miles per day with distance glasses, using one channel for his iPod and taking a break for water halfway through his run.
There was a 75-year-old female professional hiker who wanted help with her balance due to some recent stumbles. She was preparing for an upcoming hiking expedition. In therapy, she worked intensively on specialized balance board activities as well as simulated scenarios of losing her balance on uneven terrain. She realized that she was very anxious regarding her balance, which was hampering her visual attention to the trail and surrounding areas. This was the biggest factor in her losses of balance (LOBs). At the end of treatment, she flew to her desired hiking destination and hiked successfully, without any stumbles or falls!
Dr. Atanelov, thank you so much for your interesting insights on this important topic. Do you have any parting words?
Falls can change a person’s life. You may have to be taken care of, receive physical therapy, spend a lot of money on care, be hospitalized or move to a nursing home. Falls are a big problem — they can kill. The biggest message is: falls are bad. Do something about it. Don’t ignore it. Don’t say that it is nothing and make excuses. Clearly, you were not tripping when you were 20 years old!
My job is to publicize my work and teach others my method, so you can have someone give you the help you need, wherever you live in the world. I am very grateful to Hashem that I am getting wonderful results. It is clearly siyatta diShamaya — it is not me — everything is a brachah. Hashem has given me a tremendous amount of help in every way possible.
Two Clients Share Their Stories
“I am ‘only’ in my mid-50s, not a senior by any definition, yet due to various issues in my back, I was experiencing weakness and unsteadiness in my walking. Through Dr. Atanelov’s thorough exam, he identified areas of weakness in very specific muscles, and referred me to his team of talented physical therapists to strengthen those muscles. Dr. Atanelov and his staff work hand in hand to create a customized treatment plan for each patient. Hakadosh Baruch Hu has created an amazing body, with hundreds of muscles that work together and allow us to move properly. I have been to many doctors and have never seen one that identifies specific muscles by name and understands how they work together, in the manner that Dr. Atanelov does. His method is truly unique and worthy of emulation.”
“I came here because I had a problem with standing, falling and not being able to keep my balance while walk. Also, my whole right side was almost paralyzed. I had several falls; my arms would not fully stand out. I was unable to remember things. I had slurred speech and vision problems. This institute — Steady Strides — has been the key to my success. The therapist really put a lot of confidence in me. When I thought that I couldn’t do it — and on days that I felt like giving up — she gave me the motivation to continue. I’m now able to ride a motorcycle. I can do 50 push-ups and run 2 miles. I’m able to read, comprehend and I am back to 20/20 vision. Every deficiency that I had post-stroke is now recovered. And, in some areas, I recovered better.”
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