Osteopathic Considerations for the Elderly Population Keeping our patients upright and moving

1. Osteopathic Considerations for the Elderly PopulationKeeping our patients upright and moving Joy Palmer, DO Edward Via College of Osteopathic Medicine VOMA Spring CME Conference May 2010

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. Physiology of Balance • Visual • Eyes to visual Cortex • Vestibular system • Inner ear to Brainstem • Somatic sensory (joints) • Skin-muscles-joints to Spinal cord

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. 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. 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. Age-related changes to gait IT IS NOT “NORMAL” AGING TO HAVE CHANGES IN GAIT

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. Gait Classifications

10. Gait classification • Hypokinetic-rigid gait disorder • Antalgic gait • Paretic / Hypotonic • Sensory ataxic • Cautious gait • Careless gait

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. Antalgic gait • Main features of gait: • Limping • Assoc sxs and signs : • Pain • Limited range of movements

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. 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. 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. Careless Gait • Main features of gait: • Speed is inappropriately fast • Motor “recklessness” • Commonly seen in: • Huntington’s • Alzheimer’s • Confusion / delirium

17. Review of Literature

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. Review of literature • Katsura Y, et al. Effects of aquatic exercise training using water-resistance equipment in elderly. Eur J ApplPhysio, 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. Osteopathic Considerations

21. Osteopathic considerations • Whole patient : mind, body, spirit • Exercise, physical therapy • Osteopathic manipulation • Medicinal

22. Treatment models • Circulatory-Respiratory • Biomechanical/Postural/Tensegrity • Viscero-somatic/Somato-viscero • Neuro-Endocrine-Immune • Bio-energetic • Psychosomatic

23. Circulatory-Respiratory • Getting nutrients to, removing waste products from • Respiratory mechanics • Junctional areas are key sites to evaluate and address

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. Biomechanical • Posture and balance • Motion • Functional anatomy • Tensegrity

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. 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. Viscero-somatic / Somato-viscero • Facilitated segment • Reflex loop, bi-directional • Wide dynamic range cells • Chapman’s reflex

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. 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. 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. Neuro-Endocrine-Immune • Homeostasis vs allostasis • Stressful stimuli may be psychological or physiological • Hypothalamic-thyroid-adrenal-gonadal axis

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. Bioenergetic • Energy expenditure • Energy conservation • Changes in musculoskeletal system can effect body’s energy requirements.

35. Psycho-somatic • Role of limbic system in perception of pain • Depression and musculoskeletal pain

36. Treatment Approaches

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 / ligamentousarticular strain • Osteopathy in the Cranial Field • Osteopathy in the Biodynamic Field

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. 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. 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. Mechanisms of Soft Tissue • Properties of fascia contribute to effects of soft tissue approach • Mechanical • Circulatory • Neurologic • Analgesic

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 tenderpointreflective of musculoskeletal dysfunction elsewhere in the body. • Tenderpoint and associated somatic dysfunction is relieved by placing the patient into a position of ease.

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. 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. 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. 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. Mechanisms of Facilitated Positional Release • Similar to Strain-Counterstrain • Stretch reflex • Nociceptive model

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. Osteopathic manipulation for the Elderly population • Start low, go slow • Strain-Counterstrain approach • Facilitated Positional Release • Myofascial release • Soft tissue

50. Structural evaluation - junctions • Pelvis and lumbar spine • Innominates • Sacrum • Lumbars • Thoracic cage • Thorax • Ribs • Cervical spine and cranium • Extremities