90 year olds increased strength

After doing specific training for 12 weeks, people over the age of 90 improved their strength, power and muscle mass. This was reflected in an increase in their walking speed, a greater capacity to get out of their chairs, an improvement in their balance, a significant reduction in the incidence of falls and a significant improvement in muscle power and mass in the lower limbs. These are some of the outcomes of the study recently published in the Journal of the American Aging Association.

24 people between 91 and 96 participated in the research, eleven of them in the experimental group and 13 in the control group. Two days a week over a 12-week period they did multicomponent training: a program of various exercises designed specifically for them and which combined strength training and balance improving exercises. 

As Mikel Izquierdo explained, "the training raised their functional capacity, lowered the risk of falls, and improved muscle power. In addition to the significant increases in the physical capacity of frail elderly people, the study has shown that power training can be perfectly applied to the elderly with frailty."

I believe that what made this study unique and the results so promising is that the exercises were designed specifically for each individual.

What I practice and teach is to evaluate each individual not based upon their age or diagnosis but their functional and address each factor that is limiting them.

Should there be a Class Action Law Suit against Medicare?

This is an excerpt from a blog by Keddrick Stuart.

"I decided to try an experiment, recently.  I went to my neighborhood grocery store to buy the ingredients for French toast.  After the cashier rang up the eggs, I told him I’d only be paying 50% of the price of the bread and milk as part of my multiple product payment reduction plan. (MPPR)  I told him, I figured I covered most of the store’s utility costs in the eggs, and since I was combining up all my groceries in one trip, I shouldn’t have to pay over and over for his fixed costs."

Since its inception in April the average reimbursement by Medicare has decreased by 8%. 

Apparently more and more payers are getting on this bandwagon as according to the post, other non medicare providers have begun using the MPPR methodology.

As you know each CPT code is assigned as value, based upon:

• Work (skill and effort)
• Practice expense (equipment and facility costs directly related)
• Malpractice cost.
• Geography (location of the practice)

MPPR reasons that if you provide multiple services in one visit, the payer should not be required to pay the practice expense at full rate for every service in the visit, since the first service kind of covered their obligation. 

At what point do we as rehabilitation specialist need to say enough?

Is Vibration the Key to Balance?

Years ago, in Lancet (2003; 362: 1123–24) I remember reading about a study that was done where the researched put vibrators in peoples shoes and the participants improved their balance.

This study revealed that there was a reduction in seven of the eight sway parameters in young participants and all of the sway variables in elderly participants. Postural sway, has been determined to be the primary reason for falls in the elderly.

The mechanism as to why vibration may help with balance in the elderly is as follows:

• Vibration has documented circulatory effects, whereas applying a vibrating stimulus to a muscle belly has been shown to facilitate motor responses, even under pathological circumstances. This reflex muscle contraction is known as the tonic vibration reflex. 
• There are several ways vibration may potentiate muscular contraction. Together with enhancing the stretch reflex, vibration also stimulates somatosensory areas of the cortex, which can facilitate subsequent voluntary movement. 
• Increased muscle temperature, due to better perfusion and dampening of mechanical vibration, also may have a positive effect on force generation 

In my Balance Enhancement and Fall Prevention course I mention this research and suggest that appropriate patients purchase a vibrating pad, like the ones used on a car seat and rest their feet on the pad when they are sitting and performing exercises in standing.

There seems to be a resurgence in this idea as I was recently sent this link about a company producing vibrating shoes.

Want to improve Balance, Gait and Bunions?

One of the 3 primary senses involved in balance is proprioception. As people age, they lose proprioception, particularly in the most distal regions of their bodies, the hands and feet. Research has found that even if a proximal joint was replaced by surgery the proprioception in that joint was not as diminished as in the feet. Additionally it has be shown that individuals over the age of 80 are most affected by these deficits in distal proprioception.

In the foot, the primary location of propriception is located in the area around the hallux and therefore this location is a primary reason why individuals lack balance. Persons with hallux amputation experience a balance deficit of approximately 40%. Additionally, research has shown that the hallux is of particular importance to balance in forward and backward weight shift and walking.

When treating patients for proprioception we try to encourage the entire Hallux to be articulating with the floor in order to gain as much proprioceptive input as possible.

Elf Toe is a condition where the tip of the distal Hallux is curved up. It is caused by Hallux Ridigus which is a condition where the proximal phalux is hypomobile creating a hypermobility of the distal phalux and 1st Metetarsal phalangeal joint. This hypermobility can cause an arthritic bunion to form at the MTP joint. My 3 year old, started to develop such a bump. 

Because extension of the big toe is an important mechanism for the push-up phase of gate, with every step a patient with hallux ridigus is affected.

When treating this condition with the ARMS release technique, you would first stabilize the hypermobile distal phalanx, by doing this you will reveal the area of restriction of the proximal phalanx that is NOT in articulation with the floor. Then you will release the hypomobile proximal phalanx.

After treatment you would re-educate with functional exercise and/or taping. 

With this simple technique you will be treating not only balance, but bunion formation, as well as improving the quality and efficiency of gait.

The Science of Trips and Falls

The Wall Street Journal just published this article citing new research on how humans maintain their balance. 

What was of particular interest to me was that foot placement is the primary mechanism for maintaining side-to-side balance or sway.  Going along with that researchers found the biggest reason for falling, accounting for 41% of all falls, was due to incorrect weight shifting.

Clinically, I have found the same thing when I have evaluated and treated the foot and ankle;

• patient's improved their balance by at least 1 grade
• persons who could not perform single leg balance now could
• individuals who were chronic fallers, no longer fell

 In both the Foot and Ankle and Balance Enhancement and Fall Prevention Classes we evaluate and treat sway using a diagnostic motion evaluation called Foot Clocks. 

The article also mentions that the body has three main systems that help us stay balanced; The visual, proprioceptive and vestibular system.

The research has shown if at least two of these systems are impaired, people tend to have trouble with balance.  

As we know older individuals rely more on the visual system and report difficulty walking as well as experiencing a higher rate of falls at night secondary to the dark conditions. This problem is easily diagnosed and managed by prescribing glasses, surgery for cataracts, and improving home lighting. I believe that our health care system is doing an adequate job in addressing the visual component of balance.

Unfortunately,  the proprioceptive and vestibular systems are not routinely evaluated nor treated by health care professionals for the following reasons:

1. Little is know about these systems when compared to the visual system
2. They are expensive to diagnosis and manage
3. When we consider proprioception with regard to balance the most important structure is the foot. Health care professionals do not learn how to evaluate and treat the feet for balance and function 
4. Health care professionals rarely evaluate or treat the vestibular system unless there is a blatant dysfunction, like vertigo.  

The article mentions that improved diagnostic measures need to be incorporated by health care professionals to maintain the integrity of all 3 systems responsible for balance. 

To read the full article click the link below: 
http://online.wsj.com/article/SB10001424052702303983904579093560173066446.html?goback=%2Egde_2499430_member_276495644#%21