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 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

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

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

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

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

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 Obesity Postural hypotension Spinal stenosis Chronic pain Neurologic Movement disorders Stroke Visual changes White matter changes

Gait Classifications

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

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

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 test: Trendelenburg’s sign Assoc sxs and signs : Weakness Atrophy Low to absent DTRs

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

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

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

Review of Literature

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.

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.

Osteopathic Considerations

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

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

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

Osteopathic research and the Respiratory/Circulatory model O-Yurvati et al. Hemodynamic effects of OMT immediately after CABG. JAOA. 2005; 105(10): 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

Biomechanical Posture and balance Motion Functional anatomy Tensegrity

Osteopathic research and the Biomechanical model Ingber D, et al. Journal of Cell Science (article in 2 parts) Ingber D, et al. Ann. Rev. of Phys Wang, et al. PNAS

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): 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):

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

Research supporting S-V reflex Miranda A, et al. Altered visceral sensation in response to somatic pain in the rat. Gastroenterology Apr;126(4): Sato Y, et al. Reactions of cardiac postganglionic sympathetic neurons to movements of normal and inflamed knee joints. J Auton Nerv Syst Jan;12(1):1-13.

Research supporting V-S reflex Stawowy M, et al. Somatosensory changes in the referred pain area in patients with cholecystolithiasis. Eur J Gastroenterol Aug;17(8) Nicholas AS, et al. A somatic component to myocardial infarction. Br Med J (Clin Res Ed) July 6;291(6487):13-17.

Osteopathic Research and the Viscerosomatic/Somatovisceral Beal MC. JAOA. 1983; 82(11): & 1985; 85(5): Cox J. JAOA. 1983; 82(11): 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: Foreman, Blair, Ammons. Prog Brain Res. 1986; 67:

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

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: Basbaum, Levine. Can J Phsyiol Pharmacol. 1991; 69: Foreman, Blair, Ammons. Prog Brain Res. 1986; 67: Rivers WE, Treffer KD, et al. Short-Tem Hematologic and Hemodynamic Effects of Osteopathic Lymphatic Techniques: A Pilot Crossover Trial. JAOA. 2008; 108(11):

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

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 Strain-CounterStrain Facilitated Positional Release Balanced ligamentous tension / ligamentous articular strain Osteopathy in the Cranial Field Osteopathy in the Biodynamic Field

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)

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

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

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

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.

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.

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.

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:

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.

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 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

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

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

Heel of hands on anterior aspect of ASIS. Compress down towards the table and a bit lateral to assess motion at the SI joint.

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 rotation.

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 pads assessing rib one.

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. Physiologic Reviews. 2001; 81(2): Hurmuzlu Y, Basdogan C, Stoianovici D. Kinematics and dynamic stability of the locomotion of post-polio patients. J Biomech Eng Aug;118(3): Kiel DP. Falls in older persons: Risk factors and patient evaluation. UpToDate: February 3, Peterka RJ, Black FO. Age-related changes in human posture control: sensory organization tests. J Vestib Res ;1(1): Snijders A, van de Warrenburg B, Giladi N, Bloem B. Neurological gait disorders in elderly people: clinical approach and classification. vol 6, January Ward R, et al. Foundations for Osteopathic Medicine. Williams and Wilkins p 608.