Osteopathic Consideration for the Elderly Patient, Joy Palmer, D.O.
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Transcript Osteopathic Consideration for the Elderly Patient, Joy Palmer, D.O.
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
Psychotropic drug use
Lower extremity
Arthritis
weakness
Age
Female gender
Cognitive impairment
Balance problems
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): 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
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)
Ingber D, et al. Ann. Rev. of Phys. 1997.
Wang, et al. PNAS. 2001.
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): 25559.
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.
Viscero-somatic / Somato-viscero
Facilitated segment
VISCEROSOMATIC REFLEXES
Reflex loop, bi-
directional
Wide dynamic range cells
Chapman’s reflex
Figure 1
Diagram of viscerosomatic reflexes taken from:
content.answers.com/.../9/9d/360px- Gray839.png
Blue indicates PARASYMPATHETIC INNERVATION
Red indicates SYMPATHETIC INNERVATION
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.
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.
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.
Neuro-Endocrine-Immune
Homeostasis vs allostasis
Stressful stimuli may be
psychological or
physiological
Hypothalamic-thyroidadrenal-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: 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.
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
Strain-CounterStrain
Muscle energy
Facilitated Positional Release
HVLA
Balanced ligamentous
Articulatory / Still’s
tension / ligamentous
articular strain
Osteopathy in the Cranial
Field
Osteopathy in the
Biodynamic Field
Osteopathy in the Cranial
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.
Hand on femur,
moving into int
and ext rotation.
One hand on l-spine
assessing motion in
response to femur int/ext
prom .
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 cervicothoracic
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):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. 19901991;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.