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.