Dr. Jed Downs discusses common causes of falls and slips as aging sets in, and exercises and ideas for therapy that can help with balance issues.
As we age fear of falling becomes more realistic. After age 65 there is an approximate one in 5 chance of having a fall related injury. The risk is stratified and the older you are the higher your chances. The US spent $30 billion dollars on direct medical costs of fall related injuries in 2010.
Falls risks result from many issues, some of which are unique to older individuals. Intrinsic factors associated with aging include decreasing visual acuity, decreasing position sense, diminished strength, bone fragility from osteoporosis, and disease states with loss of sensory input such as diabetic neuropathy. Occasionally, there maybe disturbances of inner ear or vestibular function which place an individual at risk of falling. Some of these factors may be modifiable with osteopathic treatment as will be discussed in closing, but the public health message is to cause the older reader to think about their environment and lifestyle choices.
For indoor fall prevention, tripping hazards can be minimized by keeping floors free of clutter, especially on high traffic routes and pathways to light switches. Carpets should be taped or tacked down. Bathtubs should be equipped with non-skid surfaces and non-skid surfaces on stairs also help. Low furniture should not be near high traffic pathways.
Tripping hazards include poor choice of foot wear. Shoes with high heels or with hard smooth leather soles are slipping/tripping hazards, as are socks and slippers without adequate tread or which might fold and get caught or snagged.
As visual acuity falls off an individual needs to increase their amount of ambient lighting. Railings on both sides of stairs and grab bars in bathrooms and tubs give an individual more points to be able to stabilize their body and a chance to catch themselves if they start to fall.
Medications and alcohol alone, and especially in combination, can also put a person at risk for falling. Cardiac medications, high blood pressure medications, sleeping medications, certain antidepressants, muscle relaxants and pain medications may synergistically increase the risk of becoming lightheaded or fainting. Alcohol can cause dizziness or sleepiness, can slow reflexes and response time and can lead to risk taking behavior. It is worth reviewing one’s medications with their physician or pharmacist to see if these risks can be lessened via drug selection or via structured timing of medication dosing.
Aggressive medical management of diabetes is important as that prevents or delays damage to nerve proteins from nerve proteins being poisoned by excess sugar in the bloodstream.
Strengthening and balance practice should be among the goals of an exercise regimen in later years. Tai Chi, a practice of Chinese dance/martial arts forms, has been demonstrated to be effective and reducing the risk of falls. Physical therapy and selective exercises are useful. Practicing balancing on one foot while standing in a corner or next to a hand rail or chair, eventually challenging oneself by closing the eyes if secure, balancing on toes alternating with balancing on heels for 10 seconds at a time, standing in a corner leaning forward and taking the pelvis in a large circle both clockwise and counterclockwise are starting exercises.
With sprains and surgeries nerves are damaged. After injuries scar tissue develops and joints may not be appropriately juxtaposed. This interferes with the information the brain receives regarding position. “Garbage in equals garbage out”; if the incoming messages to the brain are not accurate, the control of the joint will not be accurate as the leg absorbs and reacts to the ground forces. Osteopathic mobilization of the joints and the soft tissues, including scar, can improve the control and range of motion of the lower extremity reducing the chances of recurrent sprains and falls. After concussion, there may be disturbances in the position of the temporal bones in the skull. This can disturb the function of the inner ear which may also impact balance. Disturbances of the facial bones can subtly alter the shape of the orbits which might slightly impair vision. These cranial relationships can often be restored with osteopathic treatment.
Fall prevention is step number one, but finding the health of position sense, vestibular system and eyes is wise to enhance optimum function as we age.
Here are links to further helpful resources:
Dr. Jed Downs explains different forms of back pain, the body systems involved with each, and general thoughts about treatments that may help with each.
Back strain: This terminology implies that muscles in the back were either too weak for the demands placed on them or that the muscles were over used. The soreness associated with a back strain will typically clear over time. Chronic over use or repeated strains secondary to using back muscles in spite of their being injured can lead to scarring or other injuries that will be slow to heal. The primary clinical finding will be local muscle tenderness with or without some increased muscle tone to splint or protect the injure tissue. Massage may help keep scar tissue from forming or at least help the tissues remodel themselves appropriately.
Back sprain: A sprain is different than a strain in that instead of overloaded muscles there has been overloading of ligaments. Ligaments are connective tissue structures that connect bones together to stabilize the skeleton. A sprain involves partial or complete tearing of a ligament. Most of the time with avoidance of repeated injurious force a ligament will heal over a period of up to 12 weeks. Repeated trauma can lead to tearing of the healing tissue and scarring that cannot be easily remodeled. Ligament injuries, especially if the ligament is completely torn, can lead to instability of a joint complex so that joint surfaces are no longer able to work together effectively. If this happens in the back seldom is there a surgical repair available unless vertebrae start slipping away from each other. (See spondylolisthesis below) The usual rehabilitation approach is core strengthening, muscle balancing, and postural cuing. Treatments such as Kinesiotaping may increase the body’s awareness of positioning and posture. Ligament injuries can be part of larger injury complexes.
Mechanical Back Pain: This is a catch all term for some providers but it can be a precise diagnosis when a practitioner has the right examination skills. Mechanical back pain means that joints are not mechanically behaving the way that they should be. There is an optimum physiologic position for the bones on either side of a joint complex. This position can be altered by forces of trauma, postural habits, summation of forces involved in lifting, by scarring, ligamentous instability, sleeping in an awkward position, etc. When the joint is out of balance there will be abnormal pressures on joint surfaces, abnormal stresses on joint capsules, the potential for disturbance of joint nutrition any of which can activate pain (nociceptive) nerves. Pain then sets up patterns of muscle spasm or muscle inhibition that can be self sustaining.
In many instances the pain will clear as the body learns to adapt and ignore the altered nerve input to the central nervous system. Most people’s bodies accumulate silent mechanical restrictions, but at some point their ability to adapt to the sum of their restrictions is overwhelmed and they become symptomatic. To reduce symptoms usually requires not just treating the most recent joint dysfunction, but also a fair portion of the body burden of accumulated restrictions. Mechanical back pain often occurs with back sprains or strains and can be a reason for slowed or lack of recovery. Mechanical problems also impair efficiency of movement and can impact job or athletic performance. Mechanical back pain occasionally will self correct but frequently benefits from mobilization (osteopathy) or manipulation (chiropractic). Some physical therapists will have a degree of mobilization skills as well.
The overlapping facet joints of the spine, the sacroiliac joints, the joints between the ribs and vertebrae can all be sources of mechanical back pain.
Discogenic back pain: The intervertebral disc is a ligamentous ring that serves as the major joint connection between levels of the spine vertebral bodies. When uninjured it has limited nerve receptors for pain but after injury, chemicals released as a result of the injury, tend to cause more pain fibers to grow. The disc is susceptible to rotational injuries and loading injuries, both acute and chronic. Its nucleus may penetrate into the layers of fibrous cartilage or herniated, tear completely through the rings of fibrocartilage. Herniation will be dealt with separately. With a tear, chemicals and proteins which have been sealed away from the body’s immune system prior to birth, can leak out and lead to an inflammatory response. Also, a torn disc will lack integrity and there will be relative instability and overstretching of nerves in the disc which can also be painful. There is limited healing potential of annular tears. Some will calm down with time others may be chronically painful while others may advance to a disc herniation. From an osteopathic perspective the initial treatment approach is to remove compression in the tissues and to make certain that adjacent spine segments, joints and soft tissues are moving well so no additional stress is placed on the injured disc. Beyond that judicious core stabilization which avoids exercises that increase internal disc pressure are added.
Disc herniation: A disc herniation occurs when the nucleus, a gel, or with aging, a putty consistency central core, is forced through the wall of the disc. These usually happen posteriorly and laterally which means that the disc is then in position to compress nerve roots which causes classic sciatic pain. The nerve root is well innervated and can express pain on the basis of mechanical or chemical irritation. Pain advances to numbness and weakness as the compression is sufficient to compromise the blood supply to the nerve root. Patterns of numbness and weakness are specific to given nerve roots. Sciatic pain without weakness can typically be managed conservatively and patients managed without surgery typically do at least as well or better than those who proceed with surgery for pain relief. Surgery is usually indicated when there is weakness. Decompressing the nerve root usually allows the nerve function to come back and the pain to clear, but there are instances in which the nerve infarcts or is partially killed off and weakness remains.
Sciatica: This is a term which commonly refers to back pain with associated pain radiating down the leg. In some circles this is the definition. In other circles there is a differentiation between sciatica which must be secondary to nerve root compression and pseudo sciatica which is back pain with leg pain that may be a result of referred pain most typically from mechanical problems of the S-I joint or a lumbo sacral facet. It is possible to experience pain in the butt and groin radiating to the knee from hip arthritis as well.
Spinal stenosis: With this diagnosis there is nerve root compression on the basis of narrowing of the openings between the bones of adjacent vertebrae or on the basis of bony arthritis that encroaches on the nerve roots centrally. The individual suffering from spinal stenosis will often be intolerant of standing upright as spine extension closes down the openings between vertebrae (foramina) leading to increased pinching of the nerve root. The spinal stenosis patient will often adopt a progressively increasing forward bent posture as flexion opens the foramina to a slight degree decompressing the nerve root. Spinal stenosis patients will have a lot of difficulty going down stairs. They may be offered surgery to remove part of the bone involved in the nerve compression. Another surgery that has been done involves the use of an X-stop device which blocks the spine from being able to go into extension at a single specific level where the stenosis is thought to be the most critical.
Failed Back Surgery Syndrome (FBSS) or Post Laminectomy Syndrome: The most common reason for FBSS is the development of scar tissue that sticks to or compresses the nerve root. ~90% of disc surgeries have good results. Scarring is part of the healing process after surgery but some individuals will generate more scar tissue than is needed and instead of tissues levels healing together the scar tissue will cross tissue layers and send out tendrils that lead to tethering of nerve tissue that needs to be free to move or that lead to frank compression of the nerve. Other reasons for FBSS include smoking as nicotine impacts bone metabolism and small blood vessels needed for healing, and misdiagnosis. Misdiagnosis may be from not recognizing all the factors causing nerve root compression or from not recognizing back pain as originating from somewhere other than a disc herniation.
Epidural fibrosis is the term used to describe the post operative scarring responsible for recurrent nerve root entrapment or fixation of the dural sac to the spine preventing its normal mobility.
Arachnoiditis: The arachnoid is the middle layer of the meninges, the layers of connective tissue that surround the spinal cord and brain. It can occur as a result of infection such as viral or bacterial meningitis. It can occur after a bleed into the cerebrospinal fluid. It can occur as a complication of an epidural injection. If the medication is supposed to go between the outer layer and the spine but instead is injected into the spinal fluid (intra thecal space) it can cause an inflammatory reaction that thickens and scars the arachnoid. Chemotherapeutic agents are sometimes intentionally injected into this space and can lead to inflammation and scarring. This is among the bad diagnoses with very limited treatment options, which are primarily limited to pain management
Visceral back pain: This is back pain that exists from either mechanical or disease processes affecting the guts. The differential is wide. It could include back pain from an expanding aortic aneurysm. It could involve pain from acute inflammation such as with pancreatitis or a stomach ulcer eroding thought the back wall of the stomach. It can be from mechanical problems arising from internal scar tissue from endometriosis, after abdominal or pelvic surgical intervention, usually >= 6 months after surgery. It can be secondary to shifting of an organ as a result of trauma. The most common organ would be a kidney issue coming on after a fall or other event with sudden deceleration or acceleration. Back pain higher up might be from twisting of the liver within its capsule. There are other scenarios but usually it is from malpositioning of a solid organ within the abdominal cavity.
Metastatic disease: There are certain tumors/cancers that have a predilection for spreading to the spine, either into vertebrae or into the spinal canal. These cancers include: breast, prostate, lung, kidney, and thyroid cancers. They spread to the spine because it is has a richer blood supply than most other bones. There are also cancers of the blood cells and bone marrow that can show up in bone as well. The most common of these is likely multiple myeloma.
Infectious disease: Tuberculosis is capable of spreading to bone and sometimes will be the first symptom announcing the arrival of the disease. Rare infections also occur in the discs. The common reasons for this are complications after medical interventions. There is a 1-2% risk following a surgical spine procedure. There is some risk after a needle has been introduced to the disc. This might be after a spinal tap or after a dye study to evaluate the integrity of the disc. It can occur spontaneously in children under the age of 8-10. It can sometimes be viral in which case spontaneous recovery is expected. The infection can be spread through the blood stream. For this reason IV drug users are at risk. It can also occur in individuals with weakened immune systems. It may be manageable with antibiotics, but it can sometimes require surgery to remove the infected materials or abscesses that develop.
Auto immune back pain or Spondyloarthropathies: There are a few types of back pain in which inflammation spontaneously occurs. These are somewhat inheritable conditions and are associated with certain types of proteins that are on the outside of cells.
Ankylosing spondylitis: Impacts the S-I joints and the lumbar spine. It can affect the joints of the ribs and sternum and can be associated with inflammation of the eyes. It is more common in males and occurs in late adolescence or early adulthood.
Reiter’s syndrome: Reiter’s syndrome is a reactive arthritis that occurs as a result of having had an infection. The S-I joint is frequently targeted but it can affect other joints outside of the back as well such as the knee or fingers. It comes on a few weeks (1-5) after having had an infection. Typically these are bacterial infections causing diarrhea or sexually transmitted diseases such as chlamydia or gonorrhea. HIV is also a risk factor.
Psoriatic arthritis: Psoriatic arthritis usually affects the joints of the lower extremities and of the distal extremities, but it can localize to the S-I joints and back. It is associated with the skin condition of psoriasis. It causes inflammation of the sites where tendons anchor into bones and can be destructive of the joints.
The uncommon types of back pain are not the focus of osteopathic manual therapy. When back pain is from outside disease processes such as infection, cancer or system wide inflammation treatment will be primarily carried out by the mainstream medical community with antibiotics, immunosuppressive, anti inflammatory medications to address diseases, pain medications of various classes, radiation therapy or surgery.
Osteopathy and its Founder
Osteopathy began as the brainchild of Andrew Taylor Still. Still served as a Hospital Steward and surgeon in the Union Army during the Civil War. After the death of three of his children from spinal meningitis, he concluded that the medicine of his day was potentially harmful and often ineffective. He took a ten year hiatus from his practice and explored the insights of native healers as well as the implications of anatomic structure on function and health.
He promoted the idea of treating the underlying structural problems — not just symptoms — and developed treatments based on an in-depth understanding of the structure of the body and how these structures interrelate with one another. After restoring balance to structural relationships, he found the body better able to recover from disease and injury. In other words, as mechanical balance and relationships were restored a patient was better able to return to function, health, and strength.
His basic findings are still the underpinnings of osteopathy:
In addition to his contributions to the art and science of medical care, A.T. Still felt strongly about gender equality: his school of osteopathy admitted women from its outset in 1892. Prior to inventing osteopathic medicine, he fought in Civil Wars in Kansas to ensure it entered the Union as a free state. He was a state legislator and an ardent abolitionist.
Dr. John Jed Downs, an osteopathic physician from Madison Manual Medicine discusses the fundamentals of osteopathic therapy, including general history, diagnostic techniques and maninpulative techniques used in therapy.
There are a number of terms that get bandied around which are largely synonymous when it comes to osteopathic manipulative therapy. Other terms that may be used include osteopathic manual therapy, osteopathic manipulative medicine, and osteopathic manual medicine. It is a pity that more people are not familiar with the terms. Osteopathy was developed in this country in the 1870’s and has been taught continuously in the US since 1892. It was developed as a complete form of medicine that was an alternative to the crude surgeries without anesthetics and the toxic drugs of the day. Current practitioners of osteopathic treatment techniques consider it a form of complementary or integrative medicine and do not seek to invalidate medical advancements that occurred during the past century.
Osteopathic manipulative medicine holds these underlying tenets:
The body is an integrated unit of mind body and spirit.
The body possesses self regulatory mechanisms and has the inherent capacity to defend, repair and remodel itself.
Structure governs function and function governs function
Rational therapy is based on consideration of the previous principles.
Traditional osteopathy as practiced internationally adds an additional tenet:
The rule of the artery is supreme.
This is understood to mean that fluid flow within the body is critical. Impediments to arterial, venous, lymphatic, spinal fluid and other flows within the body are impediments to optimal function and optimal health.
With these truths in mind, the practitioner uses his/her hands to identify the regions in the body where blockages or restrictions exist to fluid flow, blockages or restrictions of mechanical movements of the joints. These blockages may be due to trauma, be it physical, surgical or emotional, postural habits, ergonomics, repetitive or cumulative trauma, or birth trauma as either the infant or the mother. These blockages are referred to as lesions or somatic dysfunctions and can be found almost anywhere. They may occur as a result of shock waves that hit distal to a site of injury, for example falling on one’s buttocks will send a wave up the spinal structures to the neck and skull. They may be due to shearing forces between tissues during rapid acceleration or deceleration events between organs or structures of different densities. Unfortunately, it may not be possible to identify all the root causes for a symptom complex.
After finding somatic dysfunctions, the practitioner mentally maps them and prioritizes the dysfunctions, before and during the ongoing treatment process. The treatment process is controlled by the practitioner’s hands and body. Depending on the quality of the tissues in terms of texture, mobility and subtle rhythmic motions, the provider selects the appropriate technique needed to restore movement and function to a target region. She/he then observes changes in response to the initial treatment before continuing on to treat other regions. Depending on the provider’s assessment and prioritization of the patient’s body’s needs for improved health and function, she/he may not end up directly treating the area of pain or region of lost motion.
Osteopathic treatment techniques include treatments that go into the ease of tissues which allow the body to unwind or untie itself in relation to dysfunction. Techniques include direct techniques in which tissues are put on stretch, others in which the nerves and muscles are hopefully retrained, and yet other techniques that are designed to break down a restriction, osteoarticular techniques, that may or may not be associated with popping or cracking.
The examination is comprehensive and looks for impacts of restrictions on nerves, arteries, lines of gravity, the autonomic nervous system, and the capacity of the head to express movement associated with spinal fluid circulation. The spine, ribs, joints of the extremities, interfaces between organs or the insides of cavities (chest & abdomen) and joints of the skull may all need to be examined and treated in the pursuit of better health and improved function.