February 2004

Orthotic support and the older patient

by Dr. Mark Charrette

Older chiropractic patients often appreciate adjustments more because of the improved balance and coordination they achieve. The fear of injury through imbalance is justified; each year between one third and one half of those age 65 or over take a fall. [1] Not only do six percent of these falls result in fractures, but falling is also the leading cause of accidental death within the same age group. [2,3]

Balance and the orthotic connection

Chiropractors are familiar with the many health advantages of balancing the spine. The goal of custom‑made, flexible orthotics is to maximize the support provided by the feet, creating a more stable foundation, which has also been proven to improve balance and proprioception.

Postural balance is a specific and specialized function involving proprioception and is achieved when the body's center of gravity is maintained over the base formed by the feet. [4] Proprioception is the summation of various inputs from mechanoreceptors found in joint capsules, ligaments, muscles, tendons, and skin. [5] Kinesthesia involves a conscious awareness of joint position and movement resulting from proprioceptive input combined with afferent signals from the visual and vestibular systems. [6,7] Motor control coordinates an appropriate muscular response to the combined inputs, completing the feedback loop and providing a series of finely tuned adjustments, leading to postural balance.

Injuries to the lower extremity, whether acute or from chronic deformation, can alter proprioception and diminish the motor response of balance. [4] The elderly are generally faced with cumulative traumas, combined with the degenerative conditions of ligament laxity, and decreased afferent input in general. Therefore, new research that proves orthotics improve balance and proprioception is very encouraging.

Orthotics and structural support

Studies have shown that, although the loss of balance among the elderly occurs gradually and progressively over time, there are many methods for enhancing balance performance in the senior population. [8‑11] Drs. Stude and Brink have shown that experienced golfers, after wearing custom‑made, flexible orthotics daily for a period of six weeks, showed improvements in balance and proprioception. [12] This becomes significant, given the fact that experienced golfers would be expected to have maximized their coordination and balance abilities as it relates to the game of golf; and yet they did show improvement.

The results were obtained through functional tests involving single and double‑leg stances, with and without the use of sight. Many seniors become overly dependent on their vision as proprioception decreases. The authors concluded that the dysfunction in balance ability observed, comparing right and left legs before and after orthotic use, decreased and suggested that the use of orthotics promoted symmetrical balance ability and improved proprioception. [12]

Orthotics are made to address structural deficiencies, such as excessive pronation and arch integrity, in an attempt to minimize differences in structural alignment. Age has the tendency to accentuate structural deficiencies. Chiropractic adjustments of the spine improve proprioceptive input by normalizing joint alignment and muscle tonus. Furthermore, because the feet contain approximately one quarter of all the body's joints and, therefore, a concentration of proprioceptive fibers, it becomes logical to conclude that support of the postural foundation using custom‑made orthotics will enhance the balance of our patients who need it most.

References

1. Duthie EH, Jr. Falls. Med Clin North Am 1989; 73(6):1321‑1336.

2. Alexander NB, Shepard N, Gu MJ, Schultz A. "Postural control in young and elderly adults when stance is perturbed: kinematics." Journal of Gerontology 1992; 47(3):79‑82.

3. Crawford C et al. "Normative values for healthy young and elderly adult population on the KAT balance system." Issues on Aging 1995. 18;1:10‑14.

4. Irrgang JJ, Whitney SL, Cox ED. "Balance and proprioceptive training for rehabilitation of the lower extremity." J Sport Rehab 1994; 3:68‑83.

5. Grigg P. "Peripheral neural mechanisms in proprioception." J Sport Rehab 1994; 3:2‑17.

6. Garn SN, Newton RA. "Kinesthetic awareness in subjects with multiple ankle sprains." Phys Ther 1988; 11:1667‑1671.

7. Anacker SL, Di Fabio RP. "Influence of sensory inputs on standing balance in community‑dwelling elders with a recent history of falling." Phys Ther 1992; 72(8):575‑581.

8. Lord SR et al. "Exercise effect on dynamic stability in older women: a randomized controlled trial." Arch Phys Med Rehabil 1996; 77:232‑236.

9. Hughes MA et al. "The relationship of postural sway to sensorimotor function, functional performance, and disability in the elderly." Arch Phys Med Rehabil 1996; 77:567‑572.

10. Iverson BD et al. "Balance performance, force production, and activity level in noninstitutionalized men 60‑90 years of age." Phys Ther 1990; 70:348‑355.

11. Lord SR et al. "Balance, reduction time, and muscle strength in exercising and nonexercising older women: a pilot study." Arch Phys Med Rehabil 1993; 74:837‑839.

12. Stude DE, Brink DK. "Effects of nine holes of simulated golf and orthotic intervention on balance and proprioception in experienced golfers." J Manipul Physiol Ther 1997; 20(9):590‑601.

(Dr. Mark N. Charrette is a 1980 summa cum laude graduate of Palmer College of Chiropractic. Over the past 17 years he has lectured extensively on spinal and extremity adjusting throughout the U.S., Europe, the Far East, and Australia. In 1976, he received a Bachelor's degree from Illinois State University (summa cum laude) where he was an NCAA All‑American in 1974.)