Enhancing Collaboration in the Treatment of the Elderly
INTERVIEW
Interview with Dennis Enix, DC, MBA
The American Chiropractor
A former manufacturing engineer in the aerospace industry, Dr. Dennis Enix is an Associate Professor of Research at Logan University. He is a member of the Sigma Xi Scientific Research Honor Society and North American Spine Society Evidence-based Guideline Committee and is an academic editor of several scientific journals. In addition to his work with geriatric low back pain and postural control, Dr. Enix’s research includes biomechanics of the sacroiliac joint and cervical spine myodural bridges. Dr. Enix has received multiple awards for his research.
In an interview with The American Chiropractor, Dr. Enix discusses more on his chiropractic research within the geriatric population.
TAC: What is current research showing as far as falls and balance problems among the geriatric problems?
DE: The etiology of balance problems and falls are a multifactorial issue that includes multiple intrinsic and extrinsic risk factors. Fall-related risk factors include many health factors (intrinsic risks), environmental factors (extrinsic risks), behavioral issues, and medications.3,4
■ " People with low back pain have decreased spinal proprioception, slower reaction time, and lower extremity weakness, which contributes to gait and balance problems. J J
Some common predisposing factors include dizziness and vertigo, strokes and TIAs, cardiac events, hypotension, dementia, or depression. Other factors affecting balance include decreased movement reaction time, impaired vision, muscle weakness, osteoporosis, and even gait problems and poor posture, loss of physiological reserves, and, of course, polypharmacy.2,4
We know that certain prescription medications increase the risk of falls in patients 65 and older. These medicines include antipsychotics, some sedatives, and certain anti-anxiety medicines, specifically tricyclics and SSRIs, and alcohol. The American Geriatrics Society publishes a comprehensive list of medications known to increase the risk of falls called the “Beers Criteria for
Potentially Inappropriate Medication Use in Older Adults.”4 If you suspect an issue with ovennedication, a consultation with a geriatric physician can evaluate a patient for polypharmacy issues.4
TAC: Over time, has it become more widespread—what are the trends?
DE: Falls are a widespread age-related problem. One-third of community-dwelling adults over 75 and one-half of women over 85 fall every year. Eighty-seven percent of all fractures in the elderly are the result of a fall, and falls are a leading cause of injury-related deaths in the elderly.1 A history of falling is a robust predictor of morbidity among the elderly. Every 35 minutes someone dies from a fall-related injury, and 25% of all hospital admissions and 40% of all nursing home admissions are fall related.2
As startling as the current statistics on falls involving the elderly are, an estimated 60% or more falls are never reported due to fear of loss of independence. And as the age population shifts, by 2030, one in five Americans will be over 65. Research into new treatments is needed to better understand clinical issues of this complex, rapidly growing population.
TAC: Is low back pain a contributing factor to falls?
DE: This is one of the things we looked at in our geriatric falls study. Low back pain is the most frequently reported musculoskeletal complaint in individuals over the age of 60, so we expected to see a high incidence in our study, and in fact, 70% of participants reported a history of low back pain.5 It is an
important comorbidity to examine because older adults with low back pain are twice as likely to fall and have three times the difficulty performing activities of daily living.2 There is a known relationship between low back pain and an increase in both falls and fear of falling. People with low back pain have decreased spinal proprioception, slower reaction time, and lower extremity weakness, which contributes to gait and balance problems.6-7-8 A study by Radebold et al. showed that individuals with chronic low back pain have delayed trunk muscle control and worse postural control of the lumbar spine.7 Chiropractic care is an effective treatment for this condition, so we wanted to test its efficacy in this high-risk population of fallers.910
TAC: How can chiropractic care aid in the decrease of falls and balance problems?
DE: Chiropractic care may impact several of the underlying issues for individuals with balance problems.9 Simply restoring movement in arthritic joints can increase joint afferents and proprioception, improving positional awareness. An interesting study by Vaillant demonstrated that manipulation of the feet and ankles may help overcome or compensate for age-related functional decline in postural control.11 In our study, we showed that chiropractic care can effectively address chronic pain drivers that may cause postural control problems as well as directly improve balance, proprioception, and fear of falling.12
We also addressed some of the biomechanical differences seen in gait and movement patterns in fallers. In addition to a slower reaction time, there are differences in the way older adults react
to perturbations. While younger individuals tend to fall forward, older adults usually fall backward, making it more difficult to brace themselves in a fall. Older adults also tend to make large gross movements instead of fine motor skill movements to recover horn small perturbations. We try to teach people to use an “ankle strategy” instead of a “hip strategy” when they start to fall and retrain that movement behavior.
TAC: Are there other methods of treatment and what are the outcomes when using those methods?
DE: Due to the wide variety of comorbidities in individuals with balance problems, it is important to develop a team approach to caring for geriatric patients who are prone to falling.
We published a grand rounds paper in 2011 in which we describe treatment approaches from the standpoint of a chiropractor, a geriatric physician, a physical therapist, and an occupational therapist. As healthcare practitioners, we have different skill sets and approaches to caring for the faller.13 It is very important to evaluate the enviromnental risk factors in the home. Issues that extend beyond the clinic office should be addressed. The height of a bed, low toilet seats, poor lighting, upturned caipets, and the number one reason why people fall in their own home, stairs.13 Treating elderly individuals with falling issues is an opportunity to get to know other healthcare providers in your area.
We know that the most effective treatment protocols consist of a multifactorial assessment and management program. In
“The use of whole-body vibration has been shown to increase bone density and muscle mass in individuals with osteopenia and sarcopenia. J 5
addition to manipulation, which increases mobility and flexibility and restores normal joint function, an exercise program designed to improve balance and strength like a tai chi or yoga has been shown to be effective.14 A study by Chang et al. demonstrated that exercise alone reduced falls by 13% to 24%.14 The use of whole-body vibration has been shown to increase bone density and muscle mass in individuals with osteopenia and sarcopenia. A home hazard assessment should be performed to address environmental factors, and psychotropic medications should be discontinued when possible. Some patients would benefit horn the use of a walker or a three-point cane, and individuals living alone should always have a MedicAlerttype pendant.13 Falls not only break bones, they also break self-confidence. A MedicAlert pendant can provide a sense of confidence and independence while alerting a caregiver when there is a problem.13
TAC: What were you trying to accomplish with your study? And what were the outcomes?
DE: We believe that this is an important age cohort to study.
Even though the population is aging, older adults are underrepresented in randomized, controlled clinical trials.15 A recent analysis showed that the average age of individuals in low back pain studies is 44.6 years old, and that trend is actually getting younger,15 so there is a need for geriatric studies.
The primary goal of this study was to compare the effectiveness of two treatments for balance problems in the geriatric population. We randomized 168 older adults into groups that received either chiropractic or physical therapy. We know that decreased postural afferents due to a loss of joint motion and sarcopenia affect both strength, proprioceptive sensitivity, and motor control aspects of balance. We hypothesized that musculoskeletal dysfunction as well as pain is an underlying cause of postural control problems in older adults.
Since balance problems are multifactorial, we examined several static and dynamic balance measures, including movement reaction time and postural sway. We examined health-related qual-
ity of life and confidence in performing everyday activities, chronic pain levels, and pain central sensitization issues and kinesiophobia were also examined. We saw statistically significant functional improvements in gait, balance, risk of falls, and fear of falling and the ability to perform normal activities of daily living. Chronic pain improved by 40% (chiropractic group) and 48% (physical therapy group) after six weeks of care, and at twelve weeks continued to improve by 45.5% in the chiropractic group; however, pain increased by 37.3% in the physical therapy group.
TAC: Was there anything surprising, or something you didn’t expect, about the study?
DE: It’s gratifying when your research proves your null hypothesis, but there are always unexpected results. When we examined the pre-treatment and post-treatment pain scores in the two treatment groups, we saw similar decreases in pain immediately after six weeks of either chiropractic care or physical therapy. But when we examined the 12-week pain scores taken after six weeks without any treatment, we found that the pain levels in participants who received chiropractic care continued to decrease, while pain in the physical therapy group increased. By a statistically significant amount. That was an unexpected finding that we are following up on.12
TAC: Where was this information presented and what can those reading this learn from your research?
DE: We presented our study at the Saint Louis University School of Medicine Geriatrics Summer Institute Symposium in
2014, at the Ponce School of Medicine in Puerto Rico in 2015, at the World Federation of Chiropractic conference in Athens, Greece in 2015, and just last month at the Ninth Interdisciplinary World Congress on Low Back and Pelvic Pain in Singapore, where we received an award for our work.
Firstly, we want to remind clinicians of the strong relationship between chronic pain and postural control problems, especially in the geriatric population. For your patients with low back pain, a balance examination might be warranted, especially for older individuals.
Secondly, we think it is important to make the results known not only to chiropractors, but also to physicians in other disciplines and in the scientific literature. Currently our study is being included in two systematic reviews and meta-analysis of manipulation for low back pain. We hope that evidence from this study will improve care and foster collaboration between professionals and encourage referrals to a chiropractic physician when appropriate.
TAC: Do you have any more studies you’d like to conduct in the future related to this research?
DE: We are still analyzing some of the data to examine correlations between pain, kinesiophobia, and potential central sensitization issues. We would like to follow up on why chronic pain continued to decrease even after six weeks without care. We are discussing this finding with other researchers and designing a study to better examine this phenomenon.
Disclosure: This study was funded by an R18 grant from U.S. Department of Health and Human Services, Health Resources and Services Administration.
References:
1. Bressler H B, Keyes W J, Rochon P A, Badley E. The Prevalence of Low Back Pain in the Elderly, a Systematic Review of the Li terature. Spine, 1999, 24:17.
2. Rudy TE, Weiner D K, Lieber S J, Slaboda J, Boston J R. The impact of chronic low back pain on older adults: A comparative study of patients and controls. Pain, 2007, 131(3).
3. Marchetti G F, Whitney S L. Older Adults and Balance Dysfunction. Neurol Clin, 23 (2005), 785-805.
4. FlickM el al. American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc, 2015, 63:11; 2227-2246.
5. Enix DE, Sudkamp K, Malmstrom TK, Flaherty JH. Methodology and Demographics of a Single Blinded, Randomized Controlled Trial of Chiropractic Compared to Physical Therapy for Balance Impairments in Community Dwelling Geriatric Patients with or without Low Back Pain. Chiropr Man Ther, 2014, 22:31.
6. Brumagne S, Cordo P, Verschueren S. Proprioceptive weighting changes in persons with low back pain and elderly persons during upright standing. Neuroscience Letters, 366 (2004) 63-66.
7. Radebold A, Cholewicki J, Polzhofer G K, Greene H S. Impaired Postural Control of the Lumbar Spine Is Associated With Delayed Muscle Response Times inPatients With Chronic Idiopathic Low Back Pain. SPINE, 2001, 6:7.
8. Yagci N, Cavlak U, Aslan U A, Akdag B. Relationship
between balance performance and musculoskeletal pain in lower body comparison healthy middle aged and older adults. Archives of Gerontology and Geriatrics, 45 (2007), 109-119.
9. Dougherty P E, Hawk C, Weiner D K, Gleberzon B, Andrew K, KillingerL. The role of chiropractic care in older adults. Chiropractic & Manual Therapies, 2012, 20:3.
10. 10. RuheA, Fejer R, Walker B. Pain relief is associated with decreasing postural sway in patients with non-specific low back pain. BMC Musculoskeletal Disorders, 2012, 13:39.
11. VaillantJ, Vuillerme N, JanvyA, Loins F, Braujou R, Juvin R, Nougier V. Effect of manipulation of the feet and ankles on postural control in elderly adults. Brain Research Bulletin, 2008, 75; 1.
12. Enix D E, Sudkamp K, Malmstrom T K, Flaherty J H. A Randomized Controlled Trial of Chiropractic Compared to Physical Therapy for Low Back Pain in Community Dwelling Geriatric Patients. Top Integrative Healthcare, 2015.
13. Enix D E, Flaherty J H, Sudkamp K, Schultz J. Balance Problems in the Geriatric Patient, an interdisciplinary grand round. Top Integrative Health Care, 2011, 2(1).
14. Chang J Tl, Morton S C, Rubenstein L Z, Mojica W A, Maglione M, SuttorpMJ, Roth EA, Shekelle P G. Interventions for the prevention of falls in older adults: systematic review and meta-analysis of randomized clinical trials. BMJ, 2004 Mar 20, 328(7441): 680.
15. Paec T, Ferreira ML, Sun C, Lin C C, TiedemannA, Maher C G. Are older adults missing from low back pain clinical trials? - A systematic review and meta-analysis. Arthritis Care & Research, 2013.
TAC: Our sincere thanks to Dr. Enix and his team.
You may contact Dr. Dennis Enix by email:
[email protected] K£SSI
