Low-back pain is the most frequently reported musculoskeletal complaint among the senior population, and it’s one of the primary reasons why older adults tend to experience more falls as they age.
Statistics from the Centers for Disease Control and Prevention show that:
- One third of all older individuals who live on their own fall at least once a year.
- Half of all women over the age of 85 fall every year.
- Older adults with low-back pain are twice as likely to fall and have three times the difficulty performing activities of daily living.1
There is a clear relationship between low-back pain (LBP) and an increase in both falls and fear of falling. One way you can help combat this is by conducting an annual balance assessment on older patients and then providing them with appropriate action steps to improve their balance.
The importance of assessing posture
Good posture is the interdependence of form and function and, to a surprising degree, an external expression of the state of body and mind. Posture involves the body’s reflexive muscular control that balances people when they sit, stand, sleep, or work. Simply put, “posture is about how you balance your body.”2
Postural control is an often-overlooked complaint by patients, even though there is a strong correlation between chronic pain and postural control problems. Although it’s easy to think only about the structural changes seen in a hyperkyphotic patient, postural control includes the subtle patterns that keep a person in a vertical sitting or standing position even when walking or running.
Pain avoidance, manifested as fear of movement or “kinesiophobia,” impacts muscular stabilization and can affect normal posture and balance patterns. Over time, patients—particularly older adults—adapt to these altered movement patterns as pain coping mechanisms at the expense of balance, and therefore increase their risk for falls.3 This self-modulation of kinesiophobia becomes a reinforced-learning, pain-avoidance behavior, resulting in reduced motor behavior and sensory feedback, and leading to decreased lumbar control.3
Postural control research
Chiropractors have long addressed the issue of correct postural alignment, and researchers continue to investigate the importance of these changes in body alignment and balance.
A patient presenting with chronic LBP is sure to have delayed trunk muscle control and worsened postural control of the lumbar spine. Motor control researchers have demonstrated that a strong correlation exists between LBP and changes in proprioception, and that this dysfunction in the peripheral somatosensory system affects the central integration of proprioceptive information.4,5
Other studies linking posture and balance with LBP found that it causes:
- Poor voluntary control of body positioning.
- A reduction in movement control.
- Delays in movement initiation.
- Difficulty adapting to sudden surface changes.
Assessments for fall risk
Risk factors for falls are multifactorial and involve not only a patient’s medical history (intrinsic risk factors) but also environmental and behavioral factors (extrinsic risk factors), as well as any medications a patient is taking.6
There are several quick postural control assessments that can be used by a chiropractor to assess gait, balance (such as the Berg Balance Scale and the Timed Up and Go test), as well as other contributing factors such as dementia, frailty and nutritional status. While some of these concerns may be outside a practitioner’s usual care plan, they should be assessed and referred for further evaluation and care.6
Conservative approaches to improving balance
A 2009 clinical trial on geriatric falls demonstrated that chiropractic care can effectively address the chronic pain drivers that cause postural control problems as well as directly improve balance, proprioception and fear of falling—proving that doctors of chiropractic can play an important part in the prevention of recurrent falls.6
Many of the conservative approaches to improving balance are also ones that you are likely already doing in your practice for your LBP patients. A multimodal falls treatment program should consist of:
A functionally appropriate exercise program with balance and proprioception training to improve strength and reaction times and increase positional awareness.
Manipulation and mobilization of the spine, feet and ankles to restore and maintain movement in arthritic joints—increasing joint afferents and proprioception, and improving positional awareness.
Older adults tend to fall backward, often due to trying to overcompensate for a small perturbation by making a large gross movement instead of employing a fine motor skill. Exercises focused on teaching individuals to use an “ankle strategy” instead of a “hip strategy” movement if they start to fall are beneficial.
The team approach
A grand rounds paper published in 2011 described the various treatment strategies employed by a chiropractor, a geriatric physician, a physical therapist and an occupational therapist in the care of a patient with a high risk of falling.7 And because there is a wide variety of co-morbidities in individuals with balance problems, it is important to develop a team approach to caring for patients with a history of falls. Treating the elderly faller presents an opportunity to get to know other health care providers.
Because the majority of environment-related falls happen during normal activities at home, an assessment by an occupational therapist can help identify modifiable fall-risk factors and offer an opportunity to discuss some behavior modification strategies to prevent falling, such as:
- Adjusting bed and toilet height.
- Replacing poor lighting.
- Removing upturned carpets.
- Consuming more vitamin D (as low levels are strongly correlated with strength declines, low muscle mass, and decreased bone density).
Climbing stairs is the No. 1 activity causing people to fall in their own home, so a discussion of options for how to handle this should also be included. It is important to review the use of a walker or other assistive devices to provide additional stability.7 In addition, to improve safety and restore a sense of independence, a medic-alert device should always be recommended to elderly patients.
A common cause of syncopal falls in the elderly is orthostatic hypotension. Counseling a patient to get up slowly, increase salt intake (to 10 grams per day), drink two cups of coffee in the morning and avoid hot showers may help alleviate this risk. Also, the use of compression stockings can help reduce gravity-induced blood pooling in the lower extremities that increases the risk for postural hypotension.
Establish your authority
Understanding the relationship between balance, posture and LBP is an important connection for patients, the general public and other health professionals to make. The practitioner who sees patients 60 and older with LBP should incorporate rehab protocols that target balance and posture. Engaging the patient with the knowledge that strength, balance and posture training can reduce the risk of falls can increase long-term compliance and result in improved treatment outcomes.
The recent evidence-informed guidelines by the American College of Physicians on the care of LBP patients advises against formerly used medications such as NSAIDs, and now recommends alternatives offered by many DCs such as spinal manipulation and motor control exercise, which includes postural rehab exercise.8
The chiropractic profession is well positioned to integrate spinal manipulation and motor control exercise to address posture and balance for back pain and reduce the risk of falls. This well-established link between back pain and fall risk presents the chiropractic profession with another important opportunity to move from “alternative” to “cultural authority” for the treatment of fall risk in the elderly.
Steven Weiniger, DC, created the free PostureZone assessment app, the Certified Posture Exercise Professional (CPEP) program, and spearheads the PostureMonth.org public health initiative on the impact of poor posture. He is managing partner of PosturePractice.com and BodyZone.com, and can be reached at 770-922-0700 or through DrW@BodyZone.com.
Dennis Enix, DC, MBA, is an associate professor of research at Logan University, and an academic editor of several scientific journals. In addition to his work with geriatric low-back pain and postural control, Enix has received multiple awards for his research. He can be contacted through logan.edu.
References
1 Rubenstein LZ, Josephson KR. The epidemiology of falls and syncope. Clin Geriatr Med. 2002;18(2):141-58.
2 Weiniger S. (2008) Stand Taller-Live Longer, An Anti-aging Strategy. Alpharetta, GA: BodyZone Press.
3 van Dieën JH, Flor H, Hodges PW. Low-Back Pain Patients Learn to Adapt Motor Behavior with Adverse Secondary Consequences. Exerc Sport Sci Rev. 2017;45(4):223-229.
4 Gill KP, Callaghan MJ. The Measurement of Lumbar Proprioception in Individuals with and Without Low Back Pain. Spine (Phila Pa 1976). 1998;23(3):371-7.
5 della Volpe R, Popa T, Ginanneschi F, et al. Changes in Coordination of Postural Control During Dynamic Stance in Chronic Low Back Pain Patients. Gait Posture. 2006;24(3):349-55.
6 Enix DE, 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 Health Care. 2015;6(1)ID:6.1002.
7 Enix DE, Flaherty J H, Sudkamp K, Schultz J. Balance Problems in the Geriatric Patient, an interdisciplinary grand round. Top Integrative Health Care. 2011;2(1).
8 Chou R, Huffman LH. Nonpharmacologic Therapies for Acute and Chronic Low Back Pain: A Review of the Evidence for an American Pain Society/American College of Physicians Clinical Practice Guideline. Ann Intern Med. 2007;147(7):492-504.
