Balance Matters
FEATURE
Christopher Colloca
Scott Heun
Most individuals are familiar with the vestibular system that regulates balance and equilibrium in our brains; however, fewer are aware of the importance of sagittal balance and the measurable affects of proper posture on general stability. Sagittal balance implies that a patient is able to maintain a normal weight bearing line between their head and pelvis. Sagittal alignment with a proper thoracic kyphosis and lumbar lordosis is the basis of static spinal biomechanics and a fundamental element of correct posture.
Fall risk, especially in older adults, is an enormous problem facing our society. According to the CDC, one out of three adults age 65 or older fall each year W, but less than half talk to their healthcare provider about it l2L Among older adults, falls are the leading cause of both fatal and non-fatal injuries P], In 2013, 2.5 million nonfatal falls among older adults were treated in emergency rooms and more than 734,000 of these patients were hospitalized PJ. In 2012, the direct medical cost of falls, adjusted for inflation, were $30 billion in the US alone l4l. These aie just a few of the alarming statistics, but most of us are aware of specific cases where a fall is the first event that triggers a devastating downward spiral in quality of life often leading to premature death.
Combine these facts with what we know about osteoporosis, or even less severe decreases in bone-density, and the results of a fall can often become catastrophic. According to the International Osteoporosis Foundation, in the year 2000, there were an estimated 8.9 million new osteoporotic fractures, resulting in a osteoporotic fracture once every 3 seconds PJ. Of these fractures, 1.6 million were at the hip, 1.7 million were at the forearm, and 1.4 million were clinical vertebral fractures. Sixtyone percent of osteoporotic fractures occur in women - a female to male ratio of 1.6 to lPl Because of our aging population, by 2050, the incidence of hip fracture in men is projected to increase by 310%, and 240% in women I61.
How can a problem this pervasive receive so little attention, and even less specific intervention to improve the situation and its associated risks? The reasons are many and include the complicated nature of what causes falls and diminished balance over time. For instance, postural sway, a leading indicator of fall risk, is affected by multiple systems in our body and complicated by outside factors as well. These include:
• Vestibular system or the sense organs that regulate equilibrioception, our physiological sense of balance as it relates to head position and internal gravitational, linear, and angular acceleration.
• Somatosensory systems that inform us about objects in our
external environment through touch (i.e., physical contact with skin) and about the position and movement of our body parts (proprioception) through the stimulation of muscle and joints
• Visual system provides reference to verticality of body and head motion; spatial location relative to objects
• Environmental factors such as light conditions, floor surface changes, alcohol, drugs, and ear infection, also affect balance and likelihood of falling.
Our senses must constantly detect changes in spatial orientation in order maintain proper balance. Leg strength, in particular, is necessary to maintain balance and reduce the likelihood of trips and falls. Further, there are balance impairments associated with aging and age-related decline in the above systems ability to receive and integrate sensory information, which contributes to poor balance in older adultsl4L
The challenge is that these risk factors crossover from one type of practitioner to the next, with no single clinician taking on the responsibility of managing strength, balance and bone density concerns. Well-trained and experienced chiropractors aie uniquely qualified to not only raise awareness and assess fall risk, but may hold the key in treating many of the risk factors associated with falling and their impact.
Initial Assessment and Structural Analysis
To begin to manage these patients, a comprehensive patient history is the first opportunity to assess fall risk. Specific questions addressing the most common environmental factors should be made part of a patient’s initial assessment. Is a patient aware of their medications and those that affect balance? Has prescription eyewear been reassessed recently, and is vision optimized? Has an individual’s dwelling been fall-proofed and have hazards such as loose rags and clutter been addressed? There are good questionnaires out there to address these environmental concerns, but a proactive chiropractor can go much further.
Balance assessment is now an affordable option for most chiropractors. Balance plates, once a very expensive device, used by neurologists and other specialists, ai e now available and designed with the chiropractor in mind. Postural sway measurement along with asymmetric assessment can help pinpoint an individual’s center of balance and should become a standard tool in a postural assessment. The ability to measure and track data over time can help to retrain an individual to be more aware of their sagittal balance and, at a minimum, determine if someone is at a greater than normal risk for falling. Formerly, only used in biomechanics labs, combining postural sway measurement with a postural assessment, and with a thorough structural analysis that maps sagittal planes, is a major step in identifying correctable risks in clinical practice.
Beyond the assessment, specific types of training that focus on proper biomechanics, stress, muscle, bone, and connective tissue safely and efficiently have been proven to improve posture and general structure [y]. This combination of assessment, awareness, training and re-assessment can go a long way in not only preventing falls, but in strengthening the structure in order to minimize the impact of a fall.
Taking balance and fall prevention head-on in a proactive manner is a huge opportunity for the forward-thinking chiropractor to differentiate their practice in an ever increasingly competitive environment. More importantly, as experts in structure and biomechanics, the modern chiropractor has a responsibility to take the lead and intervene in this enormous societal challenge.
1. Tromp AM, Pluijm SMF, Smit JH, et al. Fall-risk screening test: a prospective study on predictors for falls in community-dwelling elderly. J Clin Epidemiol 2001 ;54(8): 837-844.
2. Stevens JA, Ballesteros MF, Mack KA, Rudd RA, DeCaro E, Adler G. Gender differences in seeking care for falls in the aged Medicare Population. American Journal of Preventive Medicine 2012;43:59-62.
3. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web-based Injury Statistics Query and Reporting System (WISQARS) [online]. Accessed August 15, 2013.
4. Stevens JA, Corso PS, Finkelstein EA, Miller TR. The costs of fatal andnonfatal falls among older adults. Injury Prevention 2006a;12:290-5.
5. Fujiwara S, NakamuraT, Orimo H, et al. (2008) Development and application of a Japanese model of the WHO fracture risk assessment tool (FRAXtrade mark). Osteoporos Int 19:429.
6. Gullberg B, Jolmell O, Kanis JA (1997) World-wide projections for hip fracture. Osteoporos Int 7:407.
7. Ellis, Gregory S.,PhD, CNS. Balance, Core Strength, Bone Health and Fall Prevention in the Aging Population - The BStrong4Life® System and Protocols
Dr. Christopher Colloca, CEO and Founder, of Neuromechanical Innovations. Over the past decade, Chris has proven to be a leader in the chiropractic forefront. He transformed chiropractic instrument adjusting delivery with his inventions of the Impulse® and Impulse iQ® Adjusting Instruments and technique applications. His inspiring and practical lectures centered on chiropractic research have moved audiences throughout the US and around the globe. Chris has built international research collaborations with some of the top scientists and physicians abroad and his award-winning research has culminated in over 50 journal publications. His expertise you can trust, his passion is uplifting, and his energy and enthusiasm are contagious.
Dr. Scott Heun is a practicing chiropractor in Napa, CA with over 30 years of clinical experience. He is also the co-founder of B·Strong4Life® www.bstrong4life.com a revolutionary company dedicated to improving core strength, balance and bone health using a proprietary system of analysis, training and patient management. In addition, he is also a sought after chiropractic advisor and mentor, specializing in patient-centered practice and doctor patient communication www.chiropracticementoring.com Dr. Heun can be reached at [email protected]
