Joy Palmer, DO
Edward Via College of Osteopathic Medicine
VOMA Spring CME Conference
May 2010
Objectives
 Understand the physiology of balance and gait
 Understand the influence of normal aging processes
on balance...
Physiology of Balance
 Visual
 Eyes to visual Cortex
 Vestibular system
 Inner ear to Brainstem
 Somatic sensory (joi...
Physiology of gait
 Cerebrum
 frontal, occipital, parietal, thalamus, basal ganglia
 Cerebellum
 Coordination of vesti...
Age-related changes to balance
 Visual
 Visual acuity, depth perception, contrast sensitivity, dark
adaptation.
 Use of...
Risk factors for falls
 Past history of a fall
 Lower extremity
weakness
 Age
 Female gender
 Cognitive impairment
 ...
Age-related changes to gait
IT IS NOT “NORMAL”
AGING TO HAVE
CHANGES IN GAIT
Disease-related changes to gait
 Acute injury
 Fractures
 Spinal stenosis
 Chronic disease
 Arthritis
 Diabetes
 Ob...
Gait Classifications
Gait classification
 Hypokinetic-rigid gait disorder
 Antalgic gait
 Paretic / Hypotonic
 Sensory ataxic
 Cautious ga...
Hypokinetic-rigid gait
 Main features of gait:
 Shuffling; slow, short stride
 reduced step height
 hesitation and fre...
Antalgic gait
 Main features of gait:
 Limping
 Assoc sxs and signs :
 Pain
 Limited range of movements
Paretic / hypotonic gait
 Main features of gait:
 High steppage
 Dropping foot
 Waddling
 Specific gait or balance te...
Sensory ataxic gait
 Main features of gait:
 Staggering
 Wide-based
 Specific gait or balance test:
 Aggravated by ey...
Cautious Gait
 Main features of gait:
 Slow, wide base, short steps
 Marked improvement with external support
 Assoc s...
Careless Gait
 Main features of gait:
 Speed is inappropriately fast
 Motor “recklessness”
 Commonly seen in:
 Huntin...
Review of Literature
Review of literature
 Manchester D et al. Visual, Vestibular and
Somatosensory Contributions to Balance Control
in the Ol...
Review of literature
 Katsura Y, et al. Effects of aquatic exercise training using
water-resistance equipment in elderly....
Osteopathic Considerations
Osteopathic considerations
 Whole patient : mind, body, spirit
 Exercise, physical therapy
 Osteopathic manipulation
 ...
Treatment models
 Circulatory-Respiratory
 Biomechanical/Postural/Tensegrity
 Viscero-somatic/Somato-viscero
 Neuro-En...
Circulatory-Respiratory
 Getting nutrients to,
removing waste products
from
 Respiratory mechanics
 Junctional areas ar...
Osteopathic research and the
Respiratory/Circulatory model
 O-Yurvati et al. Hemodynamic effects of OMT
immediately after...
Biomechanical
 Posture and balance
 Motion
 Functional anatomy
 Tensegrity
Osteopathic research and the
Biomechanical model
 Ingber D, et al. Journal of Cell Science. 2003.
(article in 2 parts)
 ...
Osteopathic research and the
Biomechanical model
 Cislo S, Ramirez M, Schwartz H. Low back pain:
Treatment of forward and...
Viscero-somatic / Somato-viscero
 Facilitated segment
 Reflex loop, bi-
directional
 Wide dynamic range cells
 Chapman...
Research supporting S-V reflex
 Miranda A, et al. Altered visceral sensation in
response to somatic pain in the rat. Gast...
Research supporting V-S reflex
 Stawowy M, et al. Somatosensory changes in the
referred pain area in patients with cholec...
Osteopathic Research and the
Viscerosomatic/Somatovisceral
 Beal MC. JAOA. 1983; 82(11): 822-31 & 1985; 85(5):
302-07.
 ...
Neuro-Endocrine-Immune
 Homeostasis vs allostasis
 Stressful stimuli may be
psychological or
physiological
 Hypothalami...
Osteopathic Research and the
Neuro-Endocrine-Immune model
 Celander E. Effect of OMT on Autonomic Tone as
Evidenced by Bl...
Bioenergetic
 Energy expenditure
 Energy conservation
 Changes in
musculoskeletal system
can effect body’s energy
requi...
Psycho-somatic
 Role of limbic system
in perception of pain
 Depression and
musculoskeletal pain
Treatment Approaches
Approaches
Direct Indirect
 Soft tissue
 Muscle energy
 HVLA
 Articulatory / Still’s
 Osteopathy in the Cranial
Field...
Structure of Fascia
 Structure:
 Loose areolar vs. dense “irregular”
 Cellular components
 Fibroblasts
 Mast cells
 ...
General Properties of Fascia
 Viscosity
 Rate of deformation under a load
 Capability to yield under continual stress
...
General Functions of Fascia
 Mechanical
 support (vascular & structural)
 compartmentalization
 conduit
 Metabolic
 ...
Mechanisms of Soft Tissue
 Properties of fascia contribute to effects of soft tissue
approach
 Mechanical
 Circulatory
...
Jones’ Strain-Counterstrain
 Jones’ tender point
 Small, hypersensitive points in the myofascial
tissues of the body use...
Mechanism of Strain-Counterstrain
 Tenderpoint arises when abnormal mm tone is
maintained through an inappropriate strain...
Golgi tendon apparatus
 Work of Korr, “Proprioceptors and Somatic
Dysfunction,” JAOA 1975
 Limitation and resistance to ...
Metabolic – Paul E. Rennie, DO
 tender point is associated with neural tissue locations
– neuromuscular junction or pierc...
Procedure
 Structural exam
 Find tenderpoint
 Establish the pain scale for the patient
 Passively position the patient...
Mechanisms of Facilitated
Positional Release
 Similar to Strain-Counterstrain
 Stretch reflex
 Nociceptive model
Procedure
 Diagnose the segment/joint/region
 Place area to be treated in “postural neutral”
 Add slight compression th...
Osteopathic manipulation for the
Elderly population
 Start low, go slow
 Strain-Counterstrain approach
 Facilitated Pos...
Structural evaluation - junctions
 Pelvis and lumbar spine
 Innominates
 Sacrum
 Lumbars
 Thoracic cage
 Thorax
 Ri...
Heel of hands on anterior
aspect of ASIS. Compress
down towards the table and
a bit lateral to assess
motion at the SI joi...
Palpate down towards
the table, then if tissues
allow, out laterally.
Place hands at posterior
pelvis so that middle
fingers are at the level of
the PSIS. Lift up on
either side to engage
rota...
One hand on l-spine
assessing motion in
response to femur int/ext
prom .
Hand on femur,
moving into int
and ext rotation.
Hands at T-L junction.
Lifting up on each side to
assess rotation.
Thumbs
contacting
transverse
processes of T1
in back; hands
resting over top
of cervico-
thoracic
junction, with
finger pa...
C-spine assessment.
OA/AA assessment.
SCM-belly
trigger point
assessment.
SCM-clavicular
trigger point
assessment.
Grasp at distal
radius/ulna. Pull up
out laterally and up
into flexion to assess
“shoulder” prom .
References
 Literature as listed in presentation
 Bosco G, Poppele RE. Proprioception From a Spinocerebellar
Perspective...
Osteopathic Considerations for the Elderly Population
Osteopathic Considerations for the Elderly Population
Osteopathic Considerations for the Elderly Population
Osteopathic Considerations for the Elderly Population
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Osteopathic Considerations for the Elderly Population

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  • At the age of 60 years old, 85% of people have a normal gait; in those aged 85 years and older, this proportion drops to 18%.Today we will focus on the physiology of staying upright and walking; disease processes that can interfere with this everyday activity; and various therapeutic interventions - including osteopathic manipulation.
  • 3 sensory systems are involved in posture and balance: visual, vestibular and somatic sensoryVisual: light waves give us orientation so that we are kept in line with the horizon. The ability to make contrast in shades of light and dark; our peripheral vision; our ability to track objects appropriately all have an impact on our posture and safe locomotion.The vestibular system utilizes the labyrinth organ which is located in the temporal bone and the cerebellum. The cochlea, semicircular canals, hair cells within the membranous labyrinth and endolymph all play a roll in adequate vestibular function. The labyrinth organ is responsible for detecting gravitation changes and angular movements of the head. The somatic sensory input is often thought of as coming from our joints. NOT TRUE!! The skin of our hands and feet contain the majority of proprioceptive fibers. In the feet are specialized fibers which relay back stretch and pressure and vibration. There is also a “shearing” type of info that plays a large role in coordinating with the visual and vestibular systems. MM involved with proprioceptive feedback includes those of the suboccipital space. These small mm can have an impact on the larger postural mm of the lumbar area – their primary function is proprioception and therefore, tell our bigger postural mm how to correct, or when to correct for imbalance or an impending fall, or when our eyes are no longer level with the horizon. The more distal extremity mm: the soleus and gastrocs play a significant role in keeping us upright as well. And then of course, the articular capsules around joint spaces and stretch/tension qualities in the ligaments associated with our facet joints, hips, knees and ankles play an equally important role in maintaining our balance.
  • Multifactorial: requires execution which includes planning, coordination; strength and timing; balance; and an ability to adapt to the environmentCerebrum send and processes the messages for planning of our anticipated path; visual cues, smooth motions, fusion of sensory info occur in the parietal cortex. As mentioned earlier, the cerebellum is a relay station for the vestibular system. It functions to coordinate movements and patterns.Thoracic rotation to left as right foot heads out to step – left sidebending in lumbars to form convexity to right – torsional locking of l-s junction as the body of the sacrum moves to the left, shifting the weight to the left to allow lifting of the right foot – as the right foot moves forward there is tensing of the quadriceps with accumulating tension at the inf pole of the right si – this locking allows slight ant movement of the left innom on the inf transverse axis - heel strike causes more tension into the hamstrings and up to the iliac crest causing a slight post motion of the right innom - iliac movement is also influenced, directed and stabilized by the torsional movement on the transverse axis at the pubic symphysis. Wow and that’s just with physical act – the kinematics… imagined if we outlined all the neural messaging that takes place!!It is a good reminder too though of all the places where somatic dysfunction can occur that can have an impact on our ability to move safely and efficiently in an upright posture.
  • There certainly are a number of age-related changes that may effect our balance. Visual, vestibular, somatosensory – if one of these is knocked out, we can generally compensate adequately and still maintain our balance. However, when 2 of these systems begin to suffer in their function, it becomes more difficult for us to maintain our balance. Even with these changes – we should not readily accept that our pts should begin to fall …. It is more along the lines of DECONDITIONING that allows pts to fall. Studies looking at gait changes in the elderly have observed that those subjects who are physically fit, do not have the same mm responses when challenged as similarly aged counterparts who are not as physically fit (manchester, ….balance control in the older adult)
  • Cause of fall is typically multifactorial. This list highlights risk factors that appeared in at least 2 clinical studies. Gait and balance impairment was the most consistent risk factor followed by medications.
  • Changes in gait are disease related, not age related. Be it acute injury, chronic pain, chronic disease or CNS changes, it is more often a matter of deconditioning than years.
  • Common disease related contributions to gait changes…many of which you see in your pts everyday – certainly many of your pts with these disease processes are not yet exhibiting changes in their gait, but certainly a reminder that gait changes is not part of “normal aging”…The underlying disease will play a large role in the cause of our pt’s gait disorder. One study looked at a subgroup of relatively healthy community residents, aged 88 y and older, of 153 residents polled, 61% reported distinct diseases as a cause of gait impairment. Non-neurological disorders were the leading causes with joint pain being the most common. Not surprisingly, stroke was the most common neurologic cause.
  • The next few slides will take a look at these 6 gait classifications; describing clinical features and associated symptoms and signs.
  • Can be assoc with parkinson’s; cerebrovasuclardx; ventricular widening.Main features of gait. : shuffling;slow, short stride; rigid; reduced step height. Hesitation and freezingSpecific gait or balance test: improves with extenal cures, aggravated by secondary taskAssoc sxs and signs: bradykinesia; resting tremor
  • Main features of gait: reduced stance phase on affected limb; limpingSpecific gait or balance test: noneAssoc signs and sxs: pain; limited range of movements
  • Could be due to : peripheral nerve entrapment; significant foraminalstenosis/ spinal stenosis; post-polio victims (****NEED TO CONFIRM THIS WITH SEARCH**)Main features of gait: High steppageDropping footWaddling Specific gait or balance test: Trendelenburg’s sign Assoc sxs and signs : Lower motor neuron features: weaknessAtrophyLow to absent DTR
  • Main features of gait: Staggering Wide-based Specific gait or balance test: Aggravated by eye closure Assoc sxs and signs : Disturbed proprioception
  • Main features of gait: Slow, wide base, short stepsMarked improvement with external support Assoc sxs and signs : Mild to moderate postural instabilityExcessive fear of falling
  • Main features of gait: Speed is inappropriately fastMotor “recklessness” Commonly seen in: Huntington’sAlzheimer’sConfusion / delirium
  • THESE articles reviewed spectrum of causes.Manchester D, Woollacott M, Zederbauer-Hylton N, Marin O. Visual, Vestibular and Somatosensory Contributions to Balance Control in the Older Adult. Journal of Gerontology. 1989;44(4): M118-27. Based on prior studies analyzing change in the somatosensory, vestibular and visual systems with age, studies were performed in order to determine whether age-related changes exist in the relative contributions of visual and somatosensory inputs to balance control. N of 32. Groups broken up into young adults (mean age 25) and older adults (mean age 68). Results: 1. In both groups strong dependence upon accurate ankle proprioceptive input for stability; 2. Proximal to distal muscle sequence reversals were not correlated with losses of balance; 3. Older adults activated antagonist mm and relied upon proximal-to-distal muscle sequencing including the hip strategy more frequently than young adults; 4. Loss of balance occurred in older adults more than younger adult group when ankle proprioception was made incongruent with postural sway and when only foveal vision was available; 5. Vestibular distortion linked to hip strategy b/c older subject may not be able to generate the appropriate ankle torque d/t peripheral neuropathy, distal motor deficits and/or muscle weakness in the lower extremity. When appropriate ankle torque cannot be generated, people will use hip mm to accommodate.; 6. Spectrum of causes may be involved with balance loss in the older adult: mm weakness, limited rom, abnormal reflexes, visual/vestibular deficits to central sensory integration problems, deficiencies in the central synergy/programming mechanism itself and motor control difficulties. Baezner H, Blahak C, Poggesi A, et al. Association of gait and balance disorders with age-related white matter changes – The LADIS Study. AAN Enterprises, Inc. 2008. N=639, multi-centered, European based, followed over 3y. Age related white matter changes measured by MRI and categorized as mild, moderate and severe. Quantitative test of gait and balance included: short physical performance battery (SPPB), a timed 8 meter walk and a timed single leg stance. Results: deficiencies in gait and balance performance were correlated with the severity of ARWMC – strong association b/w the severity of age-related white matter changes and the severity of gait and motor compromise. Physical activity might have the potential to reduce the risk of limitations in mobility.Patel M, Fransson P, Karlberg M, Malstrom E, Magnusson M. Change of Body Movement Coordination during Cervical Proprioceptive Disturbances with Increased Age. Gerontology. On-line publication: June 10, 2009. N of 34 – 18 control mean age of 29; 16 older mean age of 71. Obj: investigate whether body movement coordination strategy to calf or neck vibration was affected by aging. Measurements: body movement measured at 5 locations – ankle, knee, hip, shoulder and head) using a 3D movement measuring system. Results: older adults had a different movement pattern with neck vibration involving mainly more independent knee movements, indicating balance difficulty. Conclusion: neck vibration affects the movement pattern in older adults more compared with younger adults and calf vibration, suggesting that, the regulation of body orientation in older adults is more difficult, especially during cervical proprioceptive disturbances.
  • THESE articles all look at various therapeutic interventions for the elderly population and keeping them upright. Katsura Y, Yoshikawa T, Ueda SY, Usui T, Sotobayashi D, Nakao H, Sakamoto H, Okumtot T, Fujimoto S. Effects of aquatic exercise training using water-resistance equiptment in elderly. European Journal of Applied Physiology. 2010; 108: 957-964. This study from Japan evaluated 20 elderly participants using aquatic resistant equipment for 8 weeks to see if there was an improvement in gait and balance, which is associated with a decrease in falls. The participants were evaluated by testing physical performance and mood states. The study found that participants increased their physical fitness based on the tests and decrease their anxiety and tension by completing the aquatic exercise over the 8 w period. It was a small study size and further studies are needed with larger study size. Gill t, Baker d, et al. A Program to prevent Functional Decline in Physically Frail, Elderly Persons Who Live at Home. NEJM. 2002; 347(14): 1068-1074. Primary aim was to determine whether a home-based program designed at preventing functional decline could improve the ability of high-risk group of physically frail, elderly persons to perform essential activities of daily living, compared to those in a a control group. Secondary aim was to identify the subgroups of this elderly population that benefited most from the intervention. N = 188. Home based intervention program that included physical therapy and that focused primarily on improving underling impairments in physical abilities, including balance, muscle strength, ability to transfer form one position to another and mobility. Control group underwent an educational program. Objective measures included: change in summary disability score from baseline – checked at 3,7, and 12 months. RESULTS: participants in the intervention group had less functional decline over time. the benefit of the intervention was observed among participants with moderate frailty – but not those with severe frailty. Madureira MM, Takayama L, Gallinaro AL, Caparbo VF, Costa RA, Pereira RM. Balance training program is highly effective in improving functional status and reducing the risk of falls in elderly women with osteoporosis: a randomized controlled trial. Osteoporosis International, 2007; 18:419-425. The authors looked at the effects of a 12-month training program on balance, mobility and falling frequency. Sixty-six women over 65 with osteoporosis where randomly divided into an intervention and control group. The patients were evaluated using the Berg Balance Scale (BBS)(based on 14 items common to daily life activities), Clinical Test of Sensory Interaction for Balance (CTSIB) (testing static balance) and the Timed “Up and Go” Test (TUGT). The Balance Training program consisted of 1 hr of training once a week for 40 weeks. The patients were taught at home exercises and encouraged to do the exercises three times per week. The results found a significant difference in the intervention group than the control in the BBS and two conditions in the CTSIB. The TUGT was decreased in the intervention group as compared to the control. This study found that balance training was effective in improving balance, mobility and falling frequency in elderly women with osteoporosis.Beling J, Roller M Multifactorial Intervention with Balance Training as a Core Component Among Fall- Prone Older Adults. Journal of Geriatric Physical Therapy. 2009; 32;3:125-133. The authors conducted a small randomized controlled trial to measure the effectiveness of a balance-based program on muscle strength, gait, balance and incidence of falls in community-dwelling elderly adults. The study included 23 adults assigned to a control group or a 12-week balance-based program. The participants were assessed with a variety of test such as lower extremity manual muscles testing, range of motion testing, Timed Get Up and Go, gait analysis, balance analysis, the Berg Balance Scale and the incidence of falls. The intervention group had significantly less falls than the control group. The authors suggest that balance based training may lead to significantly less falls in the elderly but larger study size is needed.
  • Because of our education, we have all been gifted with the Osteopathic approach. Whether we incorporate osteopathic manipulation into our practice daily, we have still been ingrained with the idea that man is triune; structure and fx are interrelated; the body has a self-regulating, self-healing mechanism and that our treatment approach is based on the 3 principles. And so it is whether our pt is 2 or 12 or 82. prevention and education is a large part of what we do during our pt encounter – incorporating exercise into their daily routine – even if they are starting out with 5 minutes of walking can have a significant impact months down the road. Of course, there are many osteopathic manipulative approaches that can be safely applied to the elderly population…so taking into account again that structure and function are inter-related and that our manipulative approaches can have an impact on the muscular, skeletal, neurologic, circulatory even immunologic aspects of a segment or joint or body region, and you can have a profound treatment plan at hand. And then there’s still a medicinal application – granted in the elderly population we are often trying to minimize the amount of meds on board instead of contributing to the polypharmacy – but we can certainly maximize the amount of improvement we can get to their current “disease” processes through a pharmaceutical approach – tighter blood sugar control; improved blood pressure; dopamine agonist medications.
  • In regards to osteopathic manipulation, there are 6 physiologic models that we base our treatment procedure on. A clear understanding of these models can improve our communication with patients as well as colleagues as to the potential benefits of osteopathic manipulation. The next edition of “Foundations of Osteopathic Medicine” has a whole chapter dedicated to “treatment models”.
  • Circulatory-respiratory…primarily addressing the diaphragms of the body to maximize arterial supply, venous and lymphatic drainage. Diaphragms to consider include: medial arch of the feet- remember the navicular is the “keystone” of this arch, popliteal space, pelvic diaphragm, thoracic/abdominal diaphragm, Sibson's fascia via T1/C7, cerebellar tent, sella turcica.
  • Biomechanical/postural/tensegrity: is based on the interconnectiveness of our skeletal system, mm, ligaments, tendons, fascia. Posture, myofascial trigger points, hypertonic muscles. Treatment in this model allows for more efficient use of our muscles, and decreasing fascial restriction…freeing up organs, joints, membranes. Decrease the strain across joints, decrease the hypertonicity in their mm and they will walk more efficiently, they will actually utilize less oxygen.
  • The article by Cislo, is a review article describing the treatment of sacral torsions through newly discovered scs tp and thereby following the scs procedure protocol.Wynn’s publication reports that in their very small cross-over study, an n of 20, there was no noted significant effect to the electrical recording of reflexes, a non-significant change to the mechanical reflex response and a significant relief of sxs immediately following treatment, lasting about 48 hours.
  • Viscerosomatic/somatovisceral takes into consideration the neurologic reflex loops that become established and the resultant facilitated segments. Many reports have been published verifying segmental and visceral patterns, and histologic studies confirm the inflammatory “soup” that is found at both ends of this loop. It’s real and it’s present and we have the potential to influence it in a positive manner.
  • Miranda A: noxious somatic afferent input from the hid limb facilitates visceral hyperalgesia as measured by increased colorectal distention.Sato Y: repetitive passive motion of an inflamed knee caused an increase in blood pressure and inferior cardiac nerve activity (Passive movements in the normal working range of the joint did not influence the activity of ICN units. However, noxious joint movements, particularly of inflamed joints, led to pronounced excitation of ICN units accompanied by rises in blood pressure.)
  • Stawowy M, et al: Cholesytolithiasis leads to significant hyperalgesia in the somatic area, where pain was referred to during the acute attacks (right costal margin). Sensitivity and pain thresholds tested via pinprick, pinching, heat, cold, pressure, electrical stimulation.Nicholas AS, et al: those in group with hx of prior mi had significantly higher incidence of tissue texture changes confined almost entirely to the upper thoracics (T1-4). Control group low incidence of thoracic paraspinal asymmetry.Beal and Cox, 2 osteopaths who have done a number of studies on cardiac v-s referral patterns are another good source.
  • Growth hormone. Cortisol levels. Sex hormone stimulation. Immunologic stimulation.Neuroendocrine-immune.Utilizing anatomy to address the autonomic system…sympathetic chain ganglia, parasympathetic via cranium and sacrum. Improving balance in the autonomic system allows for improvement in the patient’s own homeostasis…improvement in their ability to compensate, to recruit inflammatory cells in response to infection…
  • Remember energy provided by nutrients we take in and ability to process those nutrients. In using this model we take into account how we can improve the metabolic/catabolic processes and how we can limit the amount of unnecessary energy expenditure. When our pt’s are acutely ill we limit our osteopathic manipulative proc to ensure that they can tolerate and adapt to the changes. Study on ql hypertonicity and work of breathing – takes more work to breath if ql are tighter – sick doesn’t need that added restriction.
  • We have spoken in the past about facilitated segments – in regards to vertebral segments. Facilitation occurs supra-tentorially as well – that is the parts of our brain that process pain become facilitated just as our lateral dorsal horns have demonstrated. I mentioned earlier that the hypothalamus ends up acting as a relay station whether the info comes from the physical or the emotional – and I’m sure we can all relate to our heart rate increasing when on a roller-coaster ride, before a practical exam, or before a lecture…Certain approaches, particularly osteopathy in the cranial field can have a direct impact on the dural membranes of the cranium and thereby have an effect on the function of the structures they surround…cranial nerves, venous sinuses, pituitary gland. Treating the soma can certainly have an impact on your pt’s psychological well-being. It is also well known in the medical community that depression and msk pain are closely linked…research shows that 20 min of vigorous exercise is an effective means of treating depression; cymbalta, a medication formally approved for depression is also being used to treat msk pain – though the exact mechanism of action hasn’t been worked out with certainty.
  • Direct, Indirect - In the end it’s all osteopathy!!!
  • Soft tissue effects:Mechanical: stretches to enhance motion/functionCirculatory: more efficient fluid movementNeurologic: stimulatory and inhibitoryAnalgesic: modulate spinal pathways
  • Intro to this osteopathic approachDefinition of tenderpoint:Definition of strain-counterstrainContinuum of myositis:Tenderpoint: coined by Lawrence Jones, DO; found in muscle or attachment of muscle; manifestation of somatic dysfunction elsewhere in the body.Trigger point: coined by Janet Travell, MD; histologic changes within a muscle that are palpable and cause pathology and musculoskeletal pain and parasthesiasfurther from site of actual trigger point location.
  • Simply put, Involves spindle apparatus: extra and intra fusal fibers; gamma receptors; alpha-1, and 2 sensory nerves. Relief reflex involves golgi tendon apparatus.“…maximal shortening to the proprioceptorrepoprting strain…it cannot report strain any longer.”- Jones
  • Korr – blames rise in the exciting gamma outflow in response to the momentarily silent proprioceptor input from the spindle of the hyper-shortened antagonist muscle, causing an inappropriate “gain” in the primary proprioceptor reflexes in its muscle spindle. When it is restrteched, it overreacts and reports strain before any real strain is reached.Counterstrain treatment brings maximal shortening to the proprioceptor reporting strain so that it cannot continue to report “strain.” The false strain message is stopped and with it the irritation and pain. Treatment itself does not cure; it only stops this irritation, finally permitting the body to cure itself. Stopping the irritation causes healing to begin.
  • tender point is associated with neural tissue locations – neuromuscular junction or piercing of nerves through the muscle.“metabolic recovery after muscle effort”Traction/compression of nerve fibers, vessels, lymphatic channelsRequirements of mm contraction and relaxationVascular and neural componentsLocal ischemia …stimulate nociceptive receptorsPoor venous and lymphatic returnMore edema and reduced blood flowResults in somatic manifestations:Elevated intramuscular pressureMuscle tension imbalanceAltered joint functionSustained nociceptive activity
  • Structural exam. Remember that these points are reflective of somatic dysfunction, namely msk, elsewhere in the body. Find tender point based on map provided by Jones (L. Jones DO, also a book has been published by Yates and Glover, both DOs. Typically found at mm attachment, mm belly or dermatome of segmental level) . Establish the pain scale for the patient. “We will call this tenderness a 10 on a scale of 1-10.”Passively position the patient into a position of ease, where the relative tenderness elicited by palpation of the same point decreases by 70%. Gently recheck the point asking the patient, “What number is it now?”Hold the patient in this position for 90 seconds while continuously monitoring the point. Monitoring is not the equivalent of “poking”. Just keep your finger on the superficial area of the point. 3 “Jeopardy” jingles equals 90 seconds.Slowly, passively, return the patient to the original starting position. The first 5-15 degrees of motion is the most important to move slowly.
  • Stretch reflex:Nociceptive model
  • Procedure for fpr
  • Out-pt setting – what we’ll go use today in lab
  • Screening of pelvis through supine slr – which is heavier?Through leg tug – knee, hip, si, t-l
  • Traction to assess SI joints
  • Hip / knee eval
  • Si compression / iliacus tp / l-s rotation
  • Iliacus tp
  • L-S rotation
  • Lumbar spine –side approach…using femur rotation to assess motion of lumbar spine vertebrae.Qleval
  • T-l junction
  • Palpation of arom of ribs: lower, middle, upper
  • Thoracic inlet
  • Cervical assessment.
  • Scm – belly and clavicular
  • Upper extremity assessment
  • Osteopathic Considerations for the Elderly Population

    1. 1. Joy Palmer, DO Edward Via College of Osteopathic Medicine VOMA Spring CME Conference May 2010
    2. 2. Objectives  Understand the physiology of balance and gait  Understand the influence of normal aging processes on balance and gait  Understand the influence of common disease processes on balance and gait  Review of literature  Osteopathic considerations in keeping our patients up-right and moving; including review of physiologic models and treatment approaches
    3. 3. Physiology of Balance  Visual  Eyes to visual Cortex  Vestibular system  Inner ear to Brainstem  Somatic sensory (joints)  Skin-muscles-joints to Spinal cord
    4. 4. Physiology of gait  Cerebrum  frontal, occipital, parietal, thalamus, basal ganglia  Cerebellum  Coordination of vestibular and proprioceptive function  Walking cycle  Upper extremities, thorax, lumbars, innominate, sacrum, lower extremities
    5. 5. Age-related changes to balance  Visual  Visual acuity, depth perception, contrast sensitivity, dark adaptation.  Use of multi-focal lenses increases risk of falls  Vestibular  Labyrinthine hair cells diminish, loss of vestibular ganglion cells, loss of nerve fibers  Somatosensory  proprioceptive sensitivity decreases: decrease in mm mass, decreased ability to make modifications in joint play, decreased ability to send message about joint position
    6. 6. Risk factors for falls  Past history of a fall  Lower extremity weakness  Age  Female gender  Cognitive impairment  Balance problems  Psychotropic drug use  Arthritis  Hx of stroke  Orthostatic hypotension  Dizziness  Anemia
    7. 7. Age-related changes to gait IT IS NOT “NORMAL” AGING TO HAVE CHANGES IN GAIT
    8. 8. Disease-related changes to gait  Acute injury  Fractures  Spinal stenosis  Chronic disease  Arthritis  Diabetes  Obesity  Postural hypotension  Spinal stenosis  Chronic pain  Neurologic  Movement disorders  Stroke  Visual changes  White matter changes
    9. 9. Gait Classifications
    10. 10. Gait classification  Hypokinetic-rigid gait disorder  Antalgic gait  Paretic / Hypotonic  Sensory ataxic  Cautious gait  Careless gait
    11. 11. Hypokinetic-rigid gait  Main features of gait:  Shuffling; slow, short stride  reduced step height  hesitation and freezing  Specific gait or balance test:  improves with external cues  aggravated by secondary task  Assoc sxs and signs:  bradykinesia; resting tremor
    12. 12. Antalgic gait  Main features of gait:  Limping  Assoc sxs and signs :  Pain  Limited range of movements
    13. 13. Paretic / hypotonic gait  Main features of gait:  High steppage  Dropping foot  Waddling  Specific gait or balance test:  Trendelenburg’s sign  Assoc sxs and signs :  Weakness  Atrophy  Low to absent DTRs
    14. 14. Sensory ataxic gait  Main features of gait:  Staggering  Wide-based  Specific gait or balance test:  Aggravated by eye closure  Assoc sxs and signs :  Disturbed proprioception
    15. 15. Cautious Gait  Main features of gait:  Slow, wide base, short steps  Marked improvement with external support  Assoc sxs and signs :  Mild to moderate postural instability  Excessive fear of falling
    16. 16. Careless Gait  Main features of gait:  Speed is inappropriately fast  Motor “recklessness”  Commonly seen in:  Huntington’s  Alzheimer’s  Confusion / delirium
    17. 17. Review of Literature
    18. 18. Review of literature  Manchester D et al. Visual, Vestibular and Somatosensory Contributions to Balance Control in the Older Adult. J of Gerontology, 1989; 44(4).  Baezner H. et al. Association of gait and balance disorders with age-related white matter changes – The LADIS Study. Neurology, 2008; 70.  Patel M, et al. Change of Body Movement Coordination during Cervical Proprioceptive Disturbances with Increased Age. Gerontology, 2009.
    19. 19. Review of literature  Katsura Y, et al. Effects of aquatic exercise training using water-resistance equipment in elderly. Eur J Appl Physio, 2010; 108.  Gill T et al. A Program to prevent Functional Decline in Physically Frail, Elderly Persons Who Live at Home. NEJM, 2002; 347.  Madureira M et al. Balance training program is highly effective in improving functional status and reducing the risk of falls in elderly women with osteoporosis: a randomized controlled trial. Osetoporosis International, 2007; 18.  Beling J, Roller M. Multifactorial Intervention with Balance Training as a Core Component Among Fall- Prone Older Adults. J of Ger Physical Therapy, 2009; 32.
    20. 20. Osteopathic Considerations
    21. 21. Osteopathic considerations  Whole patient : mind, body, spirit  Exercise, physical therapy  Osteopathic manipulation  Medicinal
    22. 22. Treatment models  Circulatory-Respiratory  Biomechanical/Postural/Tensegrity  Viscero-somatic/Somato-viscero  Neuro-Endocrine-Immune  Bio-energetic  Psychosomatic
    23. 23. Circulatory-Respiratory  Getting nutrients to, removing waste products from  Respiratory mechanics  Junctional areas are key sites to evaluate and address
    24. 24. Osteopathic research and the Respiratory/Circulatory model  O-Yurvati et al. Hemodynamic effects of OMT immediately after CABG. JAOA. 2005; 105(10): 475-80.  N=29 (10 tx group)  Findings: reduced central blood volume, mixed venous oxygen saturation increased, improved cardiac index  No particular tx protocol  Various modalities utilized
    25. 25. Biomechanical  Posture and balance  Motion  Functional anatomy  Tensegrity
    26. 26. Osteopathic research and the Biomechanical model  Ingber D, et al. Journal of Cell Science. 2003. (article in 2 parts)  Ingber D, et al. Ann. Rev. of Phys. 1997.  Wang, et al. PNAS. 2001.
    27. 27. Osteopathic research and the Biomechanical model  Cislo S, Ramirez M, Schwartz H. Low back pain: Treatment of forward and backward sacral torsions using counterstrain technique. JAOA. 1991;91(3): 255- 59.  Wynn M, Burns J, Eland D, Conatser R, Howell J. Effect of Counterstrain on Stretch Reflexes, Hoffmann Reflexes, and Clinical Outcomes in Subjects With Plantar Fasciitis. JAOA. 2006;106(9): 547-556.
    28. 28. Viscero-somatic / Somato-viscero  Facilitated segment  Reflex loop, bi- directional  Wide dynamic range cells  Chapman’s reflex VISCEROSOMATIC REFLEXES Figure 1 Diagram of viscerosomatic reflexes taken from: content.answers.com/.../9/9d/360px- Gray839.png Blue indicates PARASYMPATHETIC INNERVATION Red indicates SYMPATHETIC INNERVATION
    29. 29. Research supporting S-V reflex  Miranda A, et al. Altered visceral sensation in response to somatic pain in the rat. Gastroenterology. 2004 Apr;126(4):1082-9.  Sato Y, et al. Reactions of cardiac postganglionic sympathetic neurons to movements of normal and inflamed knee joints. J Auton Nerv Syst. 1985 Jan;12(1):1-13.
    30. 30. Research supporting V-S reflex  Stawowy M, et al. Somatosensory changes in the referred pain area in patients with cholecystolithiasis. Eur J Gastroenterol. 2005 Aug;17(8)865-70.  Nicholas AS, et al. A somatic component to myocardial infarction. Br Med J (Clin Res Ed). 1985 July 6;291(6487):13-17.
    31. 31. Osteopathic Research and the Viscerosomatic/Somatovisceral  Beal MC. JAOA. 1983; 82(11): 822-31 & 1985; 85(5): 302-07.  Cox J. JAOA. 1983; 82(11): 832-6.  N: 97  Results: greatest change in rom at T4, of these participants, 75% had angiogram evidence of CAD  Basbaum, Levine. Can J Phsyiol Pharmacol. 1991; 69: 647-651.  Foreman, Blair, Ammons. Prog Brain Res. 1986; 67: 39-48.
    32. 32. Neuro-Endocrine-Immune  Homeostasis vs allostasis  Stressful stimuli may be psychological or physiological  Hypothalamic-thyroid- adrenal-gonadal axis
    33. 33. Osteopathic Research and the Neuro-Endocrine-Immune model  Celander E. Effect of OMT on Autonomic Tone as Evidenced by Blood Pressure Changes and Activity of the Fibrinolytic System. JAOA. 1968; 67: 1037-38.  Basbaum, Levine. Can J Phsyiol Pharmacol. 1991; 69: 647-651.  Foreman, Blair, Ammons. Prog Brain Res. 1986; 67: 39-48.  Rivers WE, Treffer KD, et al. Short-Tem Hematologic and Hemodynamic Effects of Osteopathic Lymphatic Techniques: A Pilot Crossover Trial. JAOA. 2008; 108(11): 646-651.
    34. 34. Bioenergetic  Energy expenditure  Energy conservation  Changes in musculoskeletal system can effect body’s energy requirements.
    35. 35. Psycho-somatic  Role of limbic system in perception of pain  Depression and musculoskeletal pain
    36. 36. Treatment Approaches
    37. 37. Approaches Direct Indirect  Soft tissue  Muscle energy  HVLA  Articulatory / Still’s  Osteopathy in the Cranial Field  Strain-CounterStrain  Facilitated Positional Release  Balanced ligamentous tension / ligamentous articular strain  Osteopathy in the Cranial Field  Osteopathy in the Biodynamic Field
    38. 38. Structure of Fascia  Structure:  Loose areolar vs. dense “irregular”  Cellular components  Fibroblasts  Mast cells  Histiocytes  etc. (adaptability)  Subcellular components  Collagen (reticular fibers)  Elastic fibers  GAG  etc. (adaptability)
    39. 39. General Properties of Fascia  Viscosity  Rate of deformation under a load  Capability to yield under continual stress  Elasticity  Ability to recover its shape after deformation  Plasticity  The ability to retain a shape attained by deformation
    40. 40. General Functions of Fascia  Mechanical  support (vascular & structural)  compartmentalization  conduit  Metabolic  Diffusion: gel  energy storage: elastic potential energy  Immunologic  line of defense: lymphoid tissue  Barrier: compartments
    41. 41. Mechanisms of Soft Tissue  Properties of fascia contribute to effects of soft tissue approach  Mechanical  Circulatory  Neurologic  Analgesic
    42. 42. Jones’ Strain-Counterstrain  Jones’ tender point  Small, hypersensitive points in the myofascial tissues of the body used as diagnostic criteria and treatment monitors  Strain-counterstrain  Indirect treatment utilizing a myofascial tenderpoint reflective of musculoskeletal dysfunction elsewhere in the body.  Tenderpoint and associated somatic dysfunction is relieved by placing the patient into a position of ease.
    43. 43. Mechanism of Strain-Counterstrain  Tenderpoint arises when abnormal mm tone is maintained through an inappropriate strain reflex  Spindle apparatus and “Relief Reflex”.  Passively placing the patient into a position of ease (POE), allows for resetting of the neural components involved in the “strain reflex”  “Inherent corrective forces of the body – if the patient is properly positioned, his own natural forces may restore normal motion to an area.” – Rumney, KCOM, 1963  Normal resting tone is achieved, resulting in balance in the muscular system, skeletal system, neural and vascular systems.
    44. 44. Golgi tendon apparatus  Work of Korr, “Proprioceptors and Somatic Dysfunction,” JAOA 1975  Limitation and resistance to motion of a joint do not ordinarily arise w/in the joint…, but are imposed by one or more of the muscles that traverse and move the joint.  The secondary ending reports length at any moment, but the primary ending reports velocity of stretch (hence joint motion) and length (hence joint position).  Produces marked inhibitory effect on fibers when the amplitude of the stretch becomes too severe. (Jones)  Contracted position becomes “normal resting tone”; limiting range of motion and according to Rennie, maintained through self-propelled metabolic changes.
    45. 45. Metabolic – Paul E. Rennie, DO  tender point is associated with neural tissue locations – neuromuscular junction or piercing of nerves through the muscle.  “metabolic recovery after muscle effort”  Vascular and neural components  Results in somatic manifestations:
    46. 46. Procedure  Structural exam  Find tenderpoint  Establish the pain scale for the patient  Passively position the patient into a position of ease, where the relative tenderness elicited by palpation of the same point decreases by 70%  Hold the patient in this position for 90 seconds while continuously monitoring the point.  Slowly, passively, return the patient to the original starting position.  Retest the point.
    47. 47. Mechanisms of Facilitated Positional Release  Similar to Strain-Counterstrain  Stretch reflex  Nociceptive model
    48. 48. Procedure  Diagnose the segment/joint/region  Place area to be treated in “postural neutral”  Add slight compression then move tissues into their position of ease OR • Place tissues into position of ease and then add slight compression • Hold for 3-5 seconds • Recheck
    49. 49. Osteopathic manipulation for the Elderly population  Start low, go slow  Strain-Counterstrain approach  Facilitated Positional Release  Myofascial release  Soft tissue
    50. 50. Structural evaluation - junctions  Pelvis and lumbar spine  Innominates  Sacrum  Lumbars  Thoracic cage  Thorax  Ribs  Cervical spine and cranium  Extremities
    51. 51. Heel of hands on anterior aspect of ASIS. Compress down towards the table and a bit lateral to assess motion at the SI joint.
    52. 52. Palpate down towards the table, then if tissues allow, out laterally.
    53. 53. Place hands at posterior pelvis so that middle fingers are at the level of the PSIS. Lift up on either side to engage rotation.
    54. 54. One hand on l-spine assessing motion in response to femur int/ext prom . Hand on femur, moving into int and ext rotation.
    55. 55. Hands at T-L junction. Lifting up on each side to assess rotation.
    56. 56. Thumbs contacting transverse processes of T1 in back; hands resting over top of cervico- thoracic junction, with finger pads assessing rib one.
    57. 57. C-spine assessment. OA/AA assessment.
    58. 58. SCM-belly trigger point assessment. SCM-clavicular trigger point assessment.
    59. 59. Grasp at distal radius/ulna. Pull up out laterally and up into flexion to assess “shoulder” prom .
    60. 60. References  Literature as listed in presentation  Bosco G, Poppele RE. Proprioception From a Spinocerebellar Perspective. Physiologic Reviews. 2001; 81(2):539-68.  Hurmuzlu Y, Basdogan C, Stoianovici D. Kinematics and dynamic stability of the locomotion of post-polio patients. J Biomech Eng. 1996 Aug;118(3):405-11.  Kiel DP. Falls in older persons: Risk factors and patient evaluation. UpToDate: www.uptodate.com February 3, 2010.  Peterka RJ, Black FO. Age-related changes in human posture control: sensory organization tests. J Vestib Res. 1990- 1991;1(1):73-85.  Snijders A, van de Warrenburg B, Giladi N, Bloem B. Neurological gait disorders in elderly people: clinical approach and classification. www.neurology.thelancet.com vol 6, January 2007.  Ward R, et al. Foundations for Osteopathic Medicine. Williams and Wilkins. 1997. p 608.

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