Practitioner Podcast

Why Stress Is Sabotaging Your Clinical Results

December 20, 2021 by Focal Physiotherapy Leave a Comment

Transcript

Hello, and welcome back to the fourth episode of the Focal Allied Health Practitioner Podcast. What we’re going to be doing today is we’re going to be looking at the effects of psychosocial stress on our patients. And we’re basically going to be looking mostly at neuromusculoskeletal impacts. However, we will sort of discuss other aspects as well, and you can potentially extrapolate some of these, aspects to, to other aspects of patient management and, and so forth. So, you know, stick around. Let’s have a little bit of a dive into psychosocial stress and yeah, what it’s going to do of your patients. We’re also going to have a bit of a look at musculoskeletal interventions and how they may theoretically impact a person’s ability to deal with stress and traumatic events. So that’s, that’s quite interesting as well. I think where we can, potentially be helping people with stress when we are doing musculoskeletal intervention and, so forth.

Okay. So let’s go to it. So during this episode, I’m going to be referring extensively to an article by Jos Brosschot. Now, excuse me, Jos, if I’ve just butchered your name, but basically he produced a paper which was published in 2017 in the European Journal of Psychotraumatology. And there will be a link to the paper in the show notes on our website. Now, as with Jos’s article, I will refer to psychosocial stress from here simply as stress. Now, stress is, as we probably are all pretty much familiar with stress is very much a killer. They reckon that something like 50% of sick days taken by workers are due to stress. And the risks for heart disease due to stress are at least comparable to those of smoking and obesity, which is pretty crazy. When you think about it, I’d, I’d never been aware that it was that much of a problem.

So, you know, if you can help your patients manage their stress better and deal with stress, then it’s, it’s equivalent to them stopping smoking or potentially losing weight, which is, which is pretty an amazing fact. I reckon, you know, stress is something that you really want to be able to do something about and, you know, try and manage, manage your patients stress if at all, possible to try and maximize their, their outcomes. Now, a pertinent point here, and something that I really want to emphasize is that prolonged or chronic stress is what damages health. So short term responses to stress are normal and completely harmless. Well, you know, maybe depends on if they happen repeatedly and repeatedly, but in which case, maybe that it becomes chronic stress, but certainly, you know, short term in response to a particular dangerous situation, you know, that’s completely normal.

It’s a physiological response, but what happens is that when you get these prolonged aspects of, of stress, that is what ends up damaging health. Because, you know, typically if you imagine we’re out in the jungle and you know, you’ve got the tiger, that’s, you know, running after you or whatever, obviously you, you have a very acute need for stress and you, you know, you deal with it either by running away from the tiger or fighting it and killing it, or by being eaten, you know, because if you’re eaten, you’re resolving the stress at no longer becomes a problem to you. But certainly, you know, if you run away or you, you kill the tiger or whatever, then you’ve dealt with the stressor and you know, your body can relax. But the trouble with our, our modern society and our modern life is that the stress just never goes away.

You know, if you’ve got work stress, you’re overloaded. It. It’s just, it’s not an, that just happens in the short term. It’s something that sticks around and persists. And so therefore they, or those aspects are going to be having more chronic effects upon people’s health. Now Brosschot makes the reference to his research where he found that, when angered people’s blood pressure returned to normal more quickly, if they had the option of extracting some sort of revenge on the cause of the action, sorry, the anger, which to me was actually very interesting that, you know, if you have some way of, you know, basically causing revenge or getting revenge, then actually your blood pressure, returns to normal more quickly. So it tends to reduce or stress. And the interesting thing that he found about that was that you just have to have the option.

People don’t actually have to exercise that option, but when given the option to, you know, extract some sort of revenge on the cause of the anger, that is what actually caused the reduction in blood pressure more quickly after the stressful event. So you can, you know, hopefully rely on the person’s Goodwill to not actually take revenge on the person. But, that’s, that’s, I think rather an interesting thing now further research found that, when blood pressure or sorry, that blood pressure returned to normal more quickly, if people are distracted from their anger. So this is another important point. It seems that this negative sort of rumination or this chewing over the anger event is what causes the prolonged stress response. So this and negative rumination can also elicit stress responses in the body prior to exposure to the stressor. So this is important as well.

And we can all relate to this, obviously, you know, if you, if you’re doing a, say a big talk and you’re nervous about doing that talk, then obviously what’s going to happen is you’re going to start getting stressed about that because you’re ruminating over it. And you’re chewing on that, that thought that you’re going to be exposed to this stress beforehand. And it starts to this, that the stress response within your body. So this, this is not good. And this is part of the problem where the chronic stress comes from now. They, as in Brosschot’s team, they coined this term called perseverative cognition as basically the constant or perseverative, thinking about negative effects in, negative events in the past or in the future. Now perseveration in itself is a, a very interesting term, very interesting concept. And when you get into neuroscience, you sort of hear more about this term perseveration and the easiest way to explain it that I think is thinking about somebody with obsessive compulsive disorder, because we’re all fairly, fairly familiar with that these days.

And we know that some people with OCD are unable to leave the house, basically because they, they think that, well, they worry that they’ve forgotten to turn the stove off, or they worry that they haven’t locked the house and they have to go and check 10, 20 times to make sure that the, the house is locked or they haven’t forgotten to turn the stove off or whatever. So that inability to break a thought pattern or in this case, a thought pattern, but can be emotional pattern. It can be some sort of neurophysiological effect event within in the body. So perseveration can be a normal event, but it can become pathological where you just can’t break almost like the reverberating loop that is happening within the nervous system. and so that’s what they’ve sort of defined here is that this per perseverative cognition is where people are just constantly thinking about negative events to either have occurred to them, or that could be, potentially occurring to them in the future.

And so this negative perseveration rumination has been linked to the increased heart activity and hormone responses. So, so this stuff changes the body and you know, those of us that work with the body, this shouldn’t be any sort of range and wonderful thing that we are sort of hearing about here. you know, you’ve all been aware of people who get tight muscles and so forth and, you know, increased tenderness and tightness within muscles and, and so on as a consequence of this sort of getting stressed and worked up about things, but it is having autonomic effects. It’s also having endocrine effects within the body as well. And so therefore is potentially having, a lot of, negative effects within the body as well. Now there’s this thing called negative bias and research has found that most people actually tend to have a negative bias in their thoughts.

And this therefore means that we tend to sort of catastrophic size if just left to our own devices and this rather interestingly links in with daydreaming and they found that positive daydreaming actually didn’t make people happier. So, you know, you can sit there and think happy thoughts all day. It doesn’t actually tend to make people happier overall, but negative and especially noteworthy is that mutual daydreaming makes people happier. So basically the idea that people are sitting around without something to focus on and just kind of daydreaming is really only going to end up with a situation where people are at best in a neutral situation, but more likely that’s actually going to have a negative impact upon them. So people who say are in chronic pain and they’re unable to work and they’re unable get out and, and do something productive and distract themselves. They’re potentially sitting there and ruminating and daydreaming about this.

And so even if they’ve just got neutral daydreaming where they’re just sort of thinking about things and, you know, not being particularly negative, that is still going to bias them towards a more negative outlook on life. And even if they’re sitting there with a positive daydreaming experience overall, that isn’t actually going to make them happier, it’s just going to maintain the status quo is what this research thinks. sorry. Suggests. So, so that’s, that’s very interesting and makes us realize that, you know, we need to be very careful about our patients and what they’re thinking about and what they’re ruminating on basically during the day when we are not, not seeing them. And you need to be careful as well as a practitioner about what sort of thought patterns, what sort of integrative things are you reinforcing when they’re actually in the office with you? So the way I tend to sort of describe this is, you know, if you have some, anybody that comes into your office and they’re in chronic pain, or if they’re in stress or, or whatever, and you start talking about the thing that is causing the pain or the, or, sorry, talking about the pain or talking about the chronic stress events, et cetera, that’s happening within their life, then you are potentially actually going to reinforce that negative cognition.

So Mrs Jones comes in and she’s a chronic pain patient, and you say to her, hi, Mrs. Jones, how are you doing? How’s that pain doing today? You know, what things have you done during the week? Oh, did that make your pain worse, et cetera? So what we probably should be doing as a practitioner is that we should stop asking them about their pain and start asking them out the increased function within their life. And so clearly on the first visit, you need to quantify the pain. You need to sort of try and work out where they’re at and you know, what’s going on in their life and where it hurts. And you know, what are potentially the, the pain generators within the person and, you know, what, what do you need to do to actually re reduce that and how you can clear that up for the patient, et cetera.

But once they’ve got, you’ve got that initial baseline information, it would be a really good idea to not discuss pain again, in the future with that patient, at least for a good period of time, you know, do a, do a course of care and then maybe do a re-exam where you reify the pain and so forth. But at the visits in the interim, ask them to things like, you know, what extra activities were you able to do since we saw you last? What, you know, what benefits did you get? How did you get on with doing these things and, and ask them about the positive things that they’re going to have done so that you shift that negative bias away from actually reinforcing those pain messages. So just be very, very careful about that. Now, it’s also very interesting to note that exposure to negative words has been shown to increased blood pressure.

So they did this with elderly people and they exposed them to like frail and falls and unhealthy and so forth. And they found that it actually increased blood pressure, whereas positive things like active, independent, and so forth with these older adults actually tended to lower blood pressure and actually had a positive effect. So this is also are very important when you’re in practice, be very careful about using too many negative words, make sure that you’re very positive and upbeats and reinforcing the, the positive outcomes that they’re experiencing, et cetera. Okay. Now, another very interesting thing was that this, this paper was, is describing how that you actually tend to have continued autonomic changes. So things like increased heart rate, even when you are asleep. Okay. So if you have something like a stressful event, that’s coming up, so say you’ve got to do a speech the next day, and you’re not a great public speaker.

You’re not happy about it. And you go to sleep. What will happen is that your stress responses will continue to be activated even though you are asleep. Now, this is very interesting because clearly this suggests that conscious rumination cannot be the only cause of the autonomic changes here. Unconscious stress appears to be an ongoing factor within the stress responses. Now, this sort of links on further where injured and, and even dirty animals have increased corticosteroid, which is a stress hormone within the body. So somebody being stressed, it can be as a consequence of them being injured, or even just being dirty and unwashed and so forth could potentially impact upon your patients. Now, for us, maybe the dirty unwashed is less of an issue, but we are dealing with people that are injured all the time. And so you’d need to realize that just the fact that the patient is injured is going to accentuate the stress responses within that patient.

And so therefore this is going to potentially be a complicating factor with management of that patient. So this basically suggests that the default state for stress is that stress is actually earned on by default and as such, you don’t actually need a stressor within the environment. So this is amazing. Really, we’ve always tended to think that what actually happens is that people will trot along and their stress responses off. And then what happens is they encounter a dangerous situation or a, a threatening situation or whatever, and the stress response kicks in, and then they sort of maybe deal with the stress and then they go away and then the stress response goes away. And that’s not actually what appears to be the, what actually appears to be the case is that the default, the, the stress response is switched on by default. And what happens is that your prefrontal cortex actually inhibits areas within the stress, sorry, that produce stress responses such as the amygdala and so forth.

But the prefrontal cortex only does that when it perceives safety. So just think about that, that we are wired to be stressed. And the only time we actually turn that stress off is when our brain is able to inhibit that stress response. And it will only at that stress response when it feels like it’s safe now as such a person who is confident and who is at ease at the world is more likely to be inhibiting their stress responses. And in contrasts an individual who’s hypervigilant and so on, or is always expecting danger or an attack, et etc, is going to find it much more difficult to feel safe. And therefore their stress responses are more likely to, remain activated. So people who have dealt with trauma within their lives that have lent to the situation where maybe in the, as, when they were, being raised and as a child and growing up on, they may never have actually felt safe.

And so therefore they never know what it’s like to actually feel safe. And so it’s going to be very hard for those people to actually turn off that stress response because their brain is so wired that nowhere is safe. And as a consequence, they are going to find it much harder to, to deal with that. And so on. So another thing is to think about, well, what actually happens within our environment these days think about social media and that fear of missing out that those sort of tools tend to ferment within us. You know, it’s, it’s been well recognized that social media is, is very good at promoting anxiety within people that fear of missing out, you know, what am my mates doing? What am I missing out? You know, teenagers are, are having all sorts of problems with anxiety and so forth. And there’s, you know, good evidence that’s suggesting that social media is at very least a contributor to that.

And so think about that from that context that people, maybe aren’t able to turn off that because they just never feel relaxed because their phone’s buzzing at them the whole time and, you know, Johnny and their other mates, or, you know, Janine and their other mates or whatever are out there having a great time and they’re missing out, et cetera. And so it’s just firing out that stress response constantly, which is not good. Now also maybe take a person who’s injured. So whether that be back pain or ankle pain, sprain or headaches or anything like that, it’s likely that that sort of patient will feel unsafe as well because their ability to deal with of the world is compromised by their injury. So somebody who’s got back pain, for example, if they had to suddenly deal with a stressful or a threatening situation with their environment, they are not going to be able to do that as well because their back is stuffed.

And so if they had to maybe quickly move because somebody was coming at them or a car suddenly turn the corner and so on. So they’re going to be in a hypervigilant state or an increased vigilant state. And therefore their, their stress responses are likely to be increased. There’s also the interesting thing that stress responses and pain are associated. So if you can reduce your patients stress level, it’s likely to reduce your patient’s pain as well. So this is, this is an interesting concept as well. So if you have somebody who is being, being stressed and they’re releasing all this cortisol into their system and they’re releasing adrenaline and everything else, that’s likely to be facilitating pain, maybe not so much the cortisol, because that tends to have an anti-inflammatory effect, but certainly the adrenaline tends to facilitate C fiber activity and so forth nociceptive fiber activity, and is going to increase problems and potentially going to potentiate neuro neurogenic type of inflammation and so on.

So there’s all these ways that, stress is potentially going to increase pain. But if you could switch that stress off, then you are potentially going to reduce the patient’s pain and reduce the likelihood of inflammation within their body and so forth. So how might you do that? So let’s, let’s talk, maybe some nitty gritty of talked a lot of theory so far, but you could potentially make the patient feel safe. So you could try and create a calm, positive healing environment. Now, this might be difficult if you are working within a busy emergency ward in a hospital or something like this, but within a private clinic, it’s very possible that you could produce this sort of healing environment. It’s really sort of no brainer staff greet your patients with a smile, make sure your receptionists are greeting the patients with a smile, reassure your patients that they’re in the right place.

Use positive encouraging words within your interaction with the patient. And you are potentially going to decrease their pain. You can decrease their stress responses. You’re going to make them feel safe. You’re going to facilitate healing within their body. So, you know, don’t dismiss this stuff as just being woo woo, garbage, blah, blah, whatever this stuff actually, you know, there’s good physiological reasons why you would want to do this with your patients to, to facilitate the healing environment. Now, another aspect of this is that by understanding your patient’s problem, you will also potentially make them feel safe. So research found that patients don’t just want pain relief. Okay. Clearly they want that they don’t, you know, most patients come to you to get some sort of pain relief, but they don’t just want that. They want to be heard. They want to know what is going on with them.

And they want to know that you are able to help them. So the, this idea of getting a diagnosis of getting a reason why this is happening is very important for a lot of people, particularly if they don’t have, any sort of medical training, et cetera, it’s very easy for us who have got, you know, that are healthcare practitioners to forget this about our patients. You know, we kind of understand that you can’t always come up with a clear cut diagnosis and that this ambiguity in healthcare and, and, you know, you have to be dealing with a certain degree of, you know, complexity and chaos and so on within the system. And, you know, I often say to my students, you know, if you wanted black and white realities, you should have done computer science. You know, don’t, don’t come into healthcare, expecting things to be clear, cut and unambiguous.

That’s not the way it works, but the patients from patient’s perspective, they don’t understand that. And, and really, they shouldn’t have to understand that. Yes, you need to make them aware that you can’t promise anything and that, you know, you can’t guarantee them results and everything else, but it’s your job as the practitioner to find answers for them and to give them the best answer that you possibly can so that they can then come to terms with their injury or whatever. Now, I’ve actually long maintained that the purpose of a report of findings or a case discussion with a patient isn’t so much about explaining to the patient what’s go is going on though. You know, I’ve just high like that. That’s very important. It’s also about letting them know that you understand what is going on and that you are going to be able to handle it.

So they want to plan. They want a roadmap out of their situation, and they want to know that you are the person that’s going to be able to help them with it. Or if you are not the person to, to help them with them, who is, who do they need to go and see instead? And so if you feel like a patient isn’t the appropriate one for you, give them reasons why not. And give them a clear picture as to where they need to go next, who, who you going to refer them to and why this is going to be the best thing for them moving forward. And if you can give that to them, that’s going to come them down. It’s going to relax them. It’s going to help turn off those stress responses and, and facilitate healing within the body. Okay. So, so make sure you do that.

I’d like to also sort of touch on the idea of a man, the manual therapy debate. Now this has been going on within the manual therapy professions for a long time now. And a lot of people rat on manual therapy, they just think that, you know, oh, it’s just a waste of time and it facilitates dependence on, on, you know, the practitioner and it doesn’t facilitate independence, the patient and, and, you know, there’s, there’s no evidence that suggests that manual therapy has any long term value in terms of a treatment for the patient and blah, blah, blah. Now, I really think we forget the fact that patients like manual therapy and if you’ve had manual therapy, you know, particularly if you’re the type of, and that like that, I know some patients don’t particularly like it, but most patients like some sort of touch, they like some sort of, massage, or even if it’s just trigger point or even just placing your hands on the patient, it feels nice for the patient.

It helps them relax. And this whole touch aspect, a lot of people go through their lives with getting very little touch, very little human interaction in that way. And so as a practitioner, you can provide some of that and you might think, you know, oh, I’m above touching patients. And you know, I’m not being, you know, talking about unprofessional touch here. I’m talking about, you know, professional touch with the patient discount, the beneficial effects of that touch. So many people find it relaxing. It’s going to facilitate safety for the patient. It’s going to facilitate a better state of mind so that they actually feel like they are in a safe place. And therefore their prefrontal cortex is going to feel like it can start inhibiting the Amy and it’s going to relax them. And it’s going to take away all of those or not, maybe not all of it, but it’s going to reduce things like adrenaline and all those things that we know that facilitate pain and everything else.

So while yes, that you don’t want to overtreat your patients, you don’t want to make sure that they become dependent on you and, and everything else. Certainly in the short term, I see no reason why manual therapy shouldn’t be included in your patient plans. If it’s appropriate, you know, if it’s not an appropriate therapy, fine, don’t do it. But if, if there’s any doubt, do some manual therapy on people because they like it. It’s going to help put them in that, you know, safe place. And they’re going to feel better as a consequence. Now, interestingly, another thing beyond this, and, and this is kind of a bit beyond the article that we were just talking about a second ago, there’s the hippocampus within the brain. Now we know that the hippocampus area, which is on the media aspect of the temporal lobe, it’s very important for memory.

We know that at it’s very close to the entorhinal cortex, which is important for smell and so forth. And we know that the hippocampus is something that tends to suffer as we age, it’s particularly affected in many of the dementias in particular Alzheimer’s dementia, and tends to you get a lot of beater amyloid being laid down in it and tower proteins and so forth, which causes cell death stops the hippocampus working properly, which is why people tend to have memory issues fairly early, developing within Alzheimer’s. But the hippocampus is also important for what is known as fear extinct, which is learning to reduce your stress responses in response to certain stimuli. It does this in concert with the ventromedial prefrontal cortex, which is basically what we call the medial wall of the frontal lobe. So, you know, how there’s, there’s two hemispheres of the brain and on the inside of the bit that faces the bit of the, that basically faces the other part of the brain.

<laugh> I’m dunno if I’m making a particularly good explanation of that, but basically on the, the medial aspect of the frontal lobes, these areas are associated with reducing fear responses over time. Now, very interestingly, chronic pain and stress, or associated it with a decrease in volume in these brain areas. And so therefore deficiencies are going to reduce the ability to change the response to fear. So harking back to those people that I was talking about earlier, who, maybe have had traumatic events within their life, and they find it very difficult to turn the stress response off, they are going to find it harder to turn stress responses off and, and to recalibrate. So say, say they went through an abusive marriage or something like that. And they’re now out of that marriage, but they’re going to find it harder to turn the stress responses off that were maybe triggered during that marriage be you, if they have some sort of decreased volume within the hippocampus and maybe in those, prefrontal cortex areas now, and that is, is going to be more even so with, or true also with chronic pain.

So chronic pain patients, tend to have decreased brain volume in those areas as well. And so for therefore, those deficient are going to reduce the ability to change responses with fear now, fantastically and I, this is amazing exercise increases, hippocampus volume and neurogenesis. So therefore we can change hippocampus volume. And so you are therefore potentially going to be able to change patient’s ability to deal with stress within their environment through exercise. And I would also put forward that there’s a good argument, that much of the benefit that comes from this activation is due to activation of large diameter afferent fibers, such as those from muscle spindle, Golgi tendon organs, joint, mechanoreceptors, and so forth. So it’s even possible that things like manual therapies may also increase hippocampal neuronal function, and therefore potentially increase the ability to, produce fear, extinction, get rid of those fear responses, cetera.

So it seeing other physiological therapeutics such as, vibration may also do it and have calming effects on people as well. So therefore, you know, we shouldn’t just be encouraging exercise because it has physical benefits. So, you know, clearly it does. And that just in of itself is enough reason to get your patients to, to exercise, but it’s likely to actually improve the central processing of pain and improve your patient’s ability to reduce their stress responses. Okay. So we’ve, we’ve covered a lot here. I’m going to wind it up at this point, but basically we’ve looked at the fact that stress responses can be triggered by a variety of C that actually the default response for stress is for it to actually be switched on. And for it to be switched off, we actually have to have active functioning of our brain to turn those areas off, turn those stress responses off and that turning off will not occur until the patient feels like they’re in a safe environ environment to allow that to occur.

And we’ve actually covered the fact that using positive words and positive healing environments and so forth may actually help the patient turn that stress response off. And also things like physical therapies and exercise and so forth are, are potentially going to allow your patient to turn that off consciously, but also maybe longer term to remodel those stress responses within the brain. So is to actually reduce the, the overall excitability of the stress areas within the nervous system. So I hope you found that interesting. I find this topic fascinating. I hope I’ve conveyed some of that within this episode. We’ll hopefully be back with another episode in the new year while we will be back within another episode with another episode in the new year, if you’ve got any particular topics that you’d like me to discuss, et cetera, be sure to, to post a comment on the blog or something like that. But I’d love to hear from you either way and get your feedback about the podcast, how it’s going, et cetera. So thanks again for listening and hopefully I’ll speak to you soon. Okay.

So thanks for listening to our podcast. If you are an Allied Health practitioner consider working for us at focal allied health, new graduates and experience practitioners are welcome to apply head across a focalhealth.com.au/careers for current positions. Alternatively, if you are a practice owner looking to exit your practice, contact us today about making your practice a part of our team head along to focalhealth.com.au/join.

References

Brosschot JF. Ever at the ready for events that never happen. Eur J Psychotraumatol. 2017;8(1):1309934. Published 2017 Apr 10. doi:10.1080/20008198.2017.1309934

Abdallah CG, Geha P. Chronic Pain and Chronic Stress: Two Sides of the Same Coin?. Chronic Stress (Thousand Oaks). 2017;1:2470547017704763. doi:10.1177/2470547017704763

Image by Gerd Altmann from Pixabay

Photobiomodulation

December 3, 2021 by Focal Physiotherapy 1 Comment

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Episode Transcript

Hello, and welcome to episode three of the Focal Allied Health Practitioner Podcast. In this episode what we’re going to be doing is we’re going to dive into a thing which I’ve been doing quite a bit of reading about recently, and that is photobiomodulation. Now this used to be referred to as a thing called low level laser therapy, and then as things developed a little bit and became alternatives out there apart from using lasers, the term low level light therapy then started to be used. And so you may actually see it referred to as LLLT, the abbreviation shorting for low level laser therapy or low level light therapy. And what we’re going to do is we’re going to actually discuss photobiomodulation, we’re going to look at what it is and how it works, and just going to dive into that a little bit more and pull it apart and hopefully give you guys some good understanding of the mechanisms behind PBM, as I’ll refer to it as we move forward.

Okay, so like I said, it used to be referred to as low level light therapy, and then the term photobiomodulation started to become used because of the wide number of activations, or sorry, applications that PBM has been found to have. Now when I was at university I really didn’t think much of laser therapies, but that was about 25 years ago, and the technology wasn’t anything like what it is today. These days it’s become extremely widespread and there’s many, many options available, there’s very high tech laser units which will cost many tens of thousands of dollars, and you can also get things off eBay which use LEDs of certain wavelengths, and so forth, and it’s entirely possible that they all have potential therapeutic effects.

Traditionally things such as lasers were what were used, and lasers are quite unique, obviously, in that the light wave are very coherent, and as a consequence they can deliver quite a degree of energy into the tissues. However, non-coherent light sources, such as LEDs, have been found to also have an effect as well. It may well be that because they’re of a slightly lower energy they may actually be slower to have their effects, which if you’re running a busy clinic may well be a bit of an issue, and so therefore you want to get through your patient visits as quickly as you possibly can for the most effective use of your time, in which case using LED sources may not be the ideal way to do it and you may decide that lasers are more appropriate. But there certainly is quite a lot of variety that is available there these days.

Now, PBM has been used for a wide variety of conditions, people use it for tendinopathies, they use it for scar tissue. I’m personally very interested in it for its effects on brain function, like I said, but however, it can be used on many other tissues. Now it’s thought that the light with PBM can penetrate several centimetres depending upon the tissue that is being irradiated and the intensity of the light. Now interestingly wavelengths in the 600 to 700 nanometre bandwidth seem to be better for superficial tissue, and this is in the visible light spectrum, so this will be a dark, deep red sort of colour in that 600 to 700 nanometre wavelength.

Whereas your 780 to 950 nanometre wavelengths, they penetrate better into deeper tissues, and they’re getting into the near infrared spectrum. So when you actually look at those LEDs, or lasers, or whatever, not that you should look directly into a laser, because it can damage your eyes, but even so, with very intense LEDs as well, but those near infrared wavelengths, they’re obviously getting outside the visible spectrum, so you may well want to educate your patients about the fact that you’re shining this light on them and they can’t actually see anything, as to what’s actually going on there.

Now there’s a number of proposed mechanisms behind PBM, and the exact effects are going to depend upon the wavelength of light that are used. Now we’re going to focus on the red and near infrared effects of them, so that fits in with those wavelengths bands that I was talking about earlier, but I believe some people are using things like blue light for skin conditions, and so on, that’s not really something that I’ve investigated a great deal, but if that’s something that fits in with you, then do some further reading on that, I’m sure you’ll find plenty of material out there. Certainly the material seems to be increasing dramatically, and there’s a number of good systematic reviews that you can look at in that way, and even narrative reviews are out there as well.

Now let’s dive into the mechanism. So one of the primary mechanisms appears to be due to the activation of cytochrome c oxidase in the mitochondria of the cells. Now cytochrome c oxidase is part of the respiratory chain in mitochondria, and hence it’s used for energy production within the cell. Now cytochrome oxidase, cytochrome c, beg your pardon, oxidase can be reversibly deactivated by nitric oxide, and when it’s deactivated it inhibits energy production. Now when you’re looking at nitric oxide, that’s a very interesting chemical. In the mitochondria what it will do is it will actually bind to the cytochrome c oxidase, and like I said, will block the energy production, but there can be a number of ways that nitric oxide is produced.

So there’s a couple of very short term enzymes that tend to be reversible in their function, and so on, that will produce a nitric oxide, but when tissues are damaged, so when you’ve got inflammation going on, you get a more persistent form of the enzymes which produce nitric oxide, and so they can have the effect of dampening down energy production within the cell. And so it’s quite possible that some of the reparative effects of photobiomodulation, particularly in acute trauma, may actually be due to the decoupling of the produced nitric oxide, and thereby allowing energy production to resume, or a higher level of energy production to resume, within the cell, which surely is going to be a better thing when you’ve got aerobic metabolism, good support of energy metabolism within the cell, that’s generally a better outcome for cellular structures. Interestingly, the released nitric oxide also causes vasodilation and improves lymphatic flow, so it dilates the lymphatic structures as well, so you’re going to get better tissue perfusion and better lymphatic drainage from the release of nitric oxide by photobiomodulation. So that’s pretty interesting stuff, I reckon, that’s pretty great.

Now there’s also an increase in reactive oxygen species, and that is basically molecules, so these are things like free radical molecules, basically. Now your initial thought might be, well, hang on, why do we actually want to be increasing the number of free radicals within the tissue and potentially causing tissue damage and so forth? What happens is that the short term increase in free radicals actually provokes cytoprotective antioxidant and anti-apoptotic mechanisms within the cell. The consequence of this is that you actually improve the cell’s ability to deal with reactive oxygen species and free radicals, et cetera, and as a consequence you actually improve the stability of the cell.

Now, interestingly, some people find that if they use PBM too long it can actually irritate tissues and can make them worse, and I wonder whether some of the irritant type effects of photobiomodulation is actually due to increased production of these reactive oxygen species over a prolonged period of time, which actually ends up having a damaging effect, or a more marked damaging effect on the cell, and as a consequence I reckon that may well be one of the underlying mechanisms. Just my guess, but it would certainly make sense to me if that was the case.

Now other wavelengths are also effective, suggesting that there are other mechanisms at play, such as light sensitive calcium channels as well. So the mechanisms that we’ve been talking about here with the cytochrome oxidase c and the nitric oxide, and so forth, are more associated with the 600 to 700 nanometre and the 760 to 940 nanometre wavelengths, and wavelengths outside of those bandwidths don’t tend to have the same effects in releasing those nitric oxide molecules. But as we said, other wavelengths are effective, so that suggests there are other mechanisms, and these light sensitive calcium channels may well be one of them. We know that increasing calcium levels within the cell tends to lead to stimulation of gene factors, so the transduction of genes, increased protein synthesis, et cetera, so that would potentially be another mechanism that could be going on there.

Now there’s also lasting effects, which is probably due to activation of signalling and transcription factors within the cell ending up resulting in changes in protein expressions, so you’re going to get more long lasting effects, or some long lasting effects with the photobiomodulation. So you can see that it has a number of potential mechanisms that could be underlying the effects that this modality is having upon the tissues.

Now, in terms of penetration into the tissues, in this brain the skull is clearly a barrier to the penetration there, and studies vary in their theorised penetration. Some people have been saying that it goes several centimetres into brain tissue, some people are saying, well it can’t really get through the skull at all, what are you talking about? But interestingly, some of the effects that people might be seeing with, in particular, brain function may actually be due to irradiation of the bone marrow, as they’ve found that actually irradiating the long bones can have similar effects in mice. So if they radiate the mice tibia with the photobiomodulation device, it can have similar effects to irradiating the brain on brain function, which is pretty amazing, really. So it may actually be due to not so much direct irradiation of the rain, but actually these effects that are mediated via bone marrow, and so forth, as well, so that’s rather interesting stuff, I reckon.

Now in our practises we’re using photobiomodulation for the treatment of traumatic brain injury, so concussion patients, and we’re also looking at cognitive disorders like Parkinson’s and Alzheimer’s disease. Now this doesn’t work for everybody, but the early research is very promising for these conditions, and this is particularly the case given the poor prognosis of things like Parkinson’s disease and Alzheimer’s, the good safety profile of photobiomodulation, and the distinct lack of alternative effective therapies of Parkinson’s disease and Alzheimer’s. So it may well be something that we’re going to see more and more of, and I know there are some people out there that are actually using homemade light hats in effect, in things like Parkinson’s disease and Alzheimer’s, and there’s anecdotal reports of improved function as a consequence of using these light hats. So watch this space, I’m sure we’re going to see increasing research and increasing products available around this type of thing.

Now with respect to dosage, there appears to be a dose response curve. So basically you will, with this dose response curve, it’s a bit of a bell curve in effect, where you increase the level of exposure and that then tends to lead to improving effects, but then you’ll reach a peak where further irradiation doesn’t lead to further improvements, but actually tends lead to a decreasing effectiveness with continued dosing. So you do need to be aware of that When you’re actually irradiating your patients with the, it sounds rather dangerous when you say irradiating, but when you’re shining the light on your patients you’re actually going to have this dose response curve.

And very interestingly as well, the tissues with higher number of mitochondria actually need a lower dose to produce effects. Now you could theorise that that may actually be due to the fact that there’s a certain number of photons that are going to go into the tissue, and if there’s not many mitochondria in there, you’re actually going to find that most of those photons are probably going to bounce around and they’re not really going to have a great deal of effect, and only a certain number of those photons are actually going to connect with cytochrome c oxidase within the mitochondria and therefore produce an effect.

Whereas if you have increased density of mitochondria you’ve got more mitochondria for the photons to run into, so therefore you may be actually producing an effect faster as a consequence of the higher number of mitochondria, so things like bone or muscle tissues, et cetera, where there’s high numbers of mitochondria, are going to need lower doses in order to produce an effect. Simply, I suppose, because if you continue to irradiate the high number of mitochondria, you’re going to release more of these reactive oxygen species, and therefore you’re probably more likely to end up producing detrimental effects, and so forth.

Okay, now unfortunately there’s a certain amount of trial and error in dosage, and it’s very difficult for me to give recommendations here, and so I’m not even going to try, because it’s going to vary considerably based upon your equipment. Some equipment, if you are using very high tech lasers, and so forth, you may actually not need a very long dose at all, whereas if you’re using a light pad that you bought off eBay for $30, or $100, or whatever, you may actually find that you need to be irradiating the tissues for 5, 10, 15 minutes, et cetera. It’s just going to vary depending upon the device that you’re using. And so there’s a certain amount of trial and error in dose, and if the manufacturers of the device can’t give you specific advice, then you’re going to need to just “experiment” and find out what works best with the particular device that you’ve got for particular conditions, and so forth.

So I’m going to wind up this podcast there, hopefully you found this one to be interesting. I’m hoping to potentially revisit this topic further down the track when we’ve looked into it even more, and maybe we’ve got even more clinical experience, we can talk in depth more about some of these interventions, and some of the conditions that we’re using it on, and so forth. In the next podcast I’m hoping to look at stress responses and how they actually will work with musculoskeletal conditions in particular, but other types of conditions as well, and there’s some really interesting research around that, and I’m really quite keen to dive into that a little bit more.

If there’s something in particular you’d like me to discuss, then feel free to pop it in the comments. I can’t promise that I’ll be able to do everything, there’s certain limits to my time and my expertise, but I’ll try and do that, and we can start discussing some of the stuff that you guys are particularly interested in. So thanks for your attention, and I will see you again soon.

Image credit: Ron Brown https://www.science.org/content/article/trials-begin-new-weapon-against-parkinson-s-light

Assessing Falls Risks in Older Adults – Part 2

November 19, 2021 by Focal Physiotherapy Leave a Comment

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Okay. So welcome back to our second episode of the Focal Allied Health Practitioner podcast. Last episode, we talked about falls prevention and how it was a very important thing for older adults, talked about a number of factors that you want to look for. When you’re looking at falls prevention, we talked about things like intrinsic factors, environmental factors, behavioural factors that people needed to address. And then we went into a little bit more detail about some intrinsic factors and so on. And in particular, we talked about stabilometry or posture, which is the use of a force plate to measure somebody’s balance. So effectively you measure movements of the centre of gravity, the as a projection of a thing called the centre of pressure. And what that does is it basically allows you to quantify balance.

Now, as we discussed last time, there’s a number of measures that you can use to actually assess balance. One of which is sway velocity. So that is how fast the person’s centre of pressure is moving around on the force plate. And generally the faster people are moving, the more unsteady they are, you can also look at the mean distance from the centre of the sway area. So you look at how far, side to side people are swaying. So obviously the larger, the oscillations, generally the poorer the balance. Similarly, you can also do what’s called sway area where you draw a 95% confidence ellipse. And basically you work out, how wide people are swaying and etc. You come up with an “area for their sway”. And those are probably the main three measures. There’s all sorts of other sort of funky measures that everybody seems to be coming up with their own sort of determination of how to come up with sway measures and, and so on for balance.

But those are probably the main three that tend to be used. Now, in this episode, what I want to do is I want to talk about a study by Zhou and Lipsitz. So excuse me authors, if I’ve just butchered your names, but I’m pretty sure that’s correct. And I’ll put the link to this study in the show notes. So it’s an open access journal article, it’s with the Journal of NeuroEngineering and Rehabilitation. Basically the title of the article is sub-sensory vibratory noise augments the physiological complexity of postural control in older adults. So if you look that up, I’m sure you’ll be able to find a copy of that article, it’s readily available from the BMC collection there. So before, be sure to check that out. Now, this article used an interesting measure for balance and what they were doing was they were using a mathematical process called multi-scale entropy to assess the complexity of the centre of pressure sway speed.

Okay. So how fast somebody was swaying around, they were basically looking at the complexity of the sway speed. And interestingly, what they found was that the more complex the centre of pressure sway was, the better the person’s balance was. Okay, multi-scale entropy. And I won’t pretend to sort of completely understand it. I’m not a mathematician by any means, but basically what they’re doing is they’re looking at the complexity of movements. And so in this one, they were looking at centre of pressure sway speed. And like I said, they found the more complex the centre of pressure sway was the person’s balance use basically is, and they were using other more traditional balance measures for that to compare and contrast. So basically they also then discussed how postural control is critically dependent on the peripheral nervous system to detect changes in the foot’s interaction with the ground.

So not surprisingly the upshot of that was that those older adults who had better sole sensations, so they had better sensory function in the soles of their feet, had more complex balance control suggesting therefore that they had better balance. Okay, so this isn’t really surprising, but really to, I was really sort of taken by the fact that this, they were looking at this complexity of sway. And I think this is quite an interesting thing in that what tends to happen is that as we age and as our systems degenerate, they tend to become less complex.

So for example, how might you sort of explain that? So if you sort of think about, well, if you have a situation where, as a young adult, you have good visual acuity, you’ve got good visual feedback for balance. You also are potentially able to use auditory feedback for balance control as well. You can obviously use vestibular feedback, assuming, all of these systems are normal in you as an older, a younger adult, and you can use things like postural feedback or proprioceptive feedback, that are going to, to give input into the system as well. And the number and density of receptors that you have in each of these symptoms, sorry, systems is going to be greater say than in an older adult.

So for example, your number of muscle spins and the sensitivity of your muscle spins in your muscles is going to be greater. The number and density of cutaneous receptors and joint mucuna receptors is going to be greater. Your vestibular hair cells. You can to have a greater number of those, and therefore you’re going to potentially have greater sensitivity in the vestibular system. And similarly with the visual system, hopefully you’ve got fairly good visual acuity as a young adult, but obviously our retinas tend to decline as we get older, visual acuity tends to decline people, get things like cataracts, et cetera.

And so the degree of information going into the central nervous system declines as we get older. And so therefore you could say that the complexity of the system is also declining as well. So, and this is reflecting in what they were seeing with this multi-scale entropy to assess this centre of pressure sway speed, that they were seeing, that there was less complexity in the system there. Now, so what does that sort of mean for us as practitioners? Well, like I was sort of hinting at last time. You know, we are potentially going to be wanting to look at ways that we can increase feedback into our patients systems and improve better integration within the central nervous system. Because my clinical experience has been that as you start to get declines in these functions, you start to, I suppose, decrease activation within the central nervous system.

And so therefore you kind of get a bit of a winding down of the neurological system. Okay. And increasing the feedback into the system is therefore going to increase its ability to respond to perturbations from within the environment, et cetera. Now, another aspect of this study, which was very interesting was that investigating whether sub-sensory vibration applied to the soles of the feet would improve sway complexity and therefore improve functional balance. And they were using a functional test called the timed up and go test. And I’m sure many of you are familiar with that. And if you’re not, then there’s tonnes of literature out there and have a look at it.

Now, what they found was that actually, when they applied sub-sensory vibration stimulation to the soles of the feet, that you actually got increased sway complexity and timed up and go performances decreased. So as in the time that the timed up and go took to perform actually decreased with the sub-sensory noise and basically a shorter timed up and go test is a better result. And so the fact that the timed up and go improved with this sub-sensory vibration is a good thing. Now, the reasons underlying this, the why this is the case of complex and could be the, really the basis for a whole seminar, but suffice it to say basically the sub-sensory vibration lowers the activation threshold of the sensory neurons, allowing sensory information to be communicated into the central nervous system. And this isn’t surprising if you think about it from a neurophysiological point of view, if you have a neuron, which is not being fired as much, perhaps because of deafferentation, some of it’s the number of receptors maybe is decreasing or, or whatever, it could be a number of reasons.

If you are raising the feedback into the system, what you’re going to do is you’re going to increase the resting membrane potential of the neurons in that sensory system. And if the activation is sub-threshold so, so below the level of perception, then what is happening is that you’re not actually firing those receptors. You’re just raising the level of activation on them, sorry, neurons, you are just raising the level of activation on these neurons. And so what you’re therefore doing is you’re raising that resting membrane potential of the neurons, bringing it closer to the point at which the activation, sorry, the action potential is generated, and therefore you’re making it easier for subsequent sensory information i.e. Somebody’s walking around and the touch receptors are being fired in their feet. You’re making it easier for that sensory information from the walking to be propagated within the central nervous system.

So as a consequence, the patient therefore has greater sensory awareness of what is happening around them. And so therefore they’re able to deal with perturbations and issues and so forth within their environment, much more effectively than they would be able to if they didn’t have that sensory information. Okay. So these vibratory stimulations can be accessed. I believe, I think there are some companies that do it. There’s a company called Myovolt, I believe in New Zealand who are actually producing super threshold vibration stimulation. So that could potentially be beneficial as well. Cool. So a bit of a, more of a theoretical discussion this week, some of this sub-sensory threshold stimulation is harder to get clinically. A lot of these products aren’t available clinically yet. So I don’t believe that these inner soles that this group were using to actually generate the sub-threshold stimulation are, are actually clinically available yet.

But, you could potentially use some other stimulations. I know that there’s other sensory substitution mechanisms there that are being tested these days, but yeah, hopefully you found this podcast interesting. What I’m going to do is I’m just going to wind this one up here, just a little short one. I just wanted to, to touch on this. What I think was a very interesting study over the next couple of episodes, we’re going to be looking at some stuff on photobiomodulation. We’re also going to look at the things like anxiety and stress and so forth and how they may potentially alter musculoskeletal type conditions and recovery from those types of things as well. So we’ve got some interesting topic coming up. Thank you for your attention. And I will see you in the next podcast.

Reference:

Zhou, J., Lipsitz, L., Habtemariam, D. et al. Sub-sensory vibratory noise augments the physiologic complexity of postural control in older adults. J NeuroEngineering Rehabil 13, 44 (2016). https://doi.org/10.1186/s12984-016-0152-7

Assessing Falls Risks in Older Adults – Part 1

October 29, 2021 by Focal Physiotherapy Leave a Comment

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Episode Transcript

Hi, thanks for joining us with the Focal Allied Health’s Podcast. This is a podcast for practitioners who are looking to improve their clinical knowledge and skills. And this is our first episode of this brand new podcast so I’m sure it’s going to and develop and so forth as we move along. We will be having a section on our website which will be listing these podcasts so be sure to pop along and leave comments on the episodes, et cetera. I’d love to get your input, your feedback, et cetera on them, and give us some information what different topics that you would like us to cover. Also, any thoughts that you’ve got with the topics that we may raise in the episodes, et cetera. Okay.

So what we’re going to do in this first episode is that we’re going to be discussing falls risks. Now, clearly this is a huge topic, and we’re only going to be able to address a small part of that today. However, is a very important topic, and it’s one which particularly for older adults is a very pressing and timely thing that needs to be looked at.

One of the things that makes it such an important thing to address is that there’s a very high risk of falls, or high rate of falls in older adults. So once people get over the age of 60, 65 the rate of falls increases to about 1:3 per year, which is quite high. It’s 33% of people are going to fall in a given year. And the problem with that is that there is a very real risk of injury and death occurring when people fall. And as a consequence of that, there’s a lot of costs associated with that for the healthcare system. There’s also a lot of cost associated with that for individuals, et cetera. And so falls are something that we very much need to address in our older population.

Now, one of the real issues, one of the additional issues is that when people suffer a fall as an older adult it’s frequently associated with loss of independence. Now, the way that this works is that quite often if people fall they start to become quite anxious and very fearful quite often about leaving the house, and going out, and engaging in public, and so forth. So, as a consequence they can become much more isolated. They can become cut off from the rest of society, and with all that loss of independence that comes with it. Associated with that you will often get anxiety issues and depression that develops as well. We are looking not only just at the physical aspect of falls, but we are looking at the implications to the individual from a psychological perspective, and issues around mental health, and independence, and ability to engage in the fun activities of life, to get some juice out of life and make life worth living for these older adults. So, this is an important thing.

The other aspect is that as people fall there is an increased chance that they’re going to move into aged care. Now, the problem with that is, apart from the cost aspect, is that this will often lead to further losses of independence for the individual. And rather depressingly, the falls risk actually usually increases further when people get into aged care. So you’re looking at it increases to 1:2 people in a year will fall when they get into aged care.

Now there’s many factors associated with that. Some of these are things like the muscle deconditioning that tends to occur within environments like that. Quite often people aren’t… Either they’re not encouraged to become more active and maintain their independence, or they are encouraged, but they don’t have the motivation to do so. And these facilities quite often don’t have the staffing requirements that could be going along and motivating each individual person, not a one- on-one basis, et cetera. So there’s all sorts of factors at play there. So, clearly it makes sense to try and actually stop the individual getting to the situation where they’re going to end up in aged care. And there’s thankfully quite a number of things that we can actually do to make sure that that is the case.

Now, when you’re looking at falls risk, generally we categorise three groups of factors that can predispose somebody to having a fall. Now, one of these groups is environmental factors. Another one of them is behavioural factors. And another one is what we call intrinsic factors.

Now, environmental factors are things like falls risk aspects around the house, for example. So things like loose rugs in the house, electrical cables that might be there for people to trip on, poor steps, or uneven steps, or uneven pathways, et cetera that pose trip hazards in the garden, et cetera. So there’s all sorts of factors that people can look at to try and reduce the environmental aspect, and there’s many, many environmental risk factor checklists which are available. You could just do a Google for falls risk checklists and quite often you’ll come up with all sorts of different lists that you can use, and that you can give to your patients or give to their kids or whatever. And they can then go round and audit their home, or you may well even decide that you want to offer that service to your patients where you can go round to their home and evaluate their falls risks and so forth. Okay.

So, with those environmental factors are a very important one and they have to be dealt with because it clearly makes no sense to have dodgy rugs lying around on the floor that somebody’s going to trip on. You can address all sorts of other aspects, but if they’ve got factors like that going on then it’s just going to predispose them to unnecessary risk.

Now, another factor, as I said, is behavioural aspects. Now, people need to be counselled not to take risks. It’s natural when you get older to want to try and maintain your independence. That’s almost a given. But what can happen is that people can take risks which are not proportional to their abilities, so to be trying to do things that they were able to do maybe 20 years ago is silly. Climbing up things like ladders, for example, using things like chairs to climb up to high cupboards as opposed to using a nice stable step ladder, or even better, maybe not even having high cupboards altogether so that there’s no temptation to try and climb up to reach those high cupboards. Things like walking dogs. You sometimes see older people walking dogs and the dogs are almost far too strong for that older adult. And if the dog cleared off, saw a cat or something like that and ran off, they may well pull the person over. You’ll sometimes see people getting dog leads caught up around their legs, and those sort of trip hazards, et cetera.

So there’s a wide variety of things which can impact upon your patient’s fall risk that are behaviour related. And so, one of the things that you are going to need to do as a healthcare professional is that you’re actually going to need to counsel your patients on those, and talk about some of the things that they do, and raise some of those topics with them, and try and work out what they can do to actually try and reduce the falls risk through behavioural modification. Okay. So that’s something that definitely needs to be done as well.

Now, the last group of factors is what is often referred to as intrinsic factors. And to me, this is actually quite the exciting part for us, particularly those of you that are listening that are physical therapy type based. So whether that be a physiotherapist, or a chiropractor, or an osteopath, or something like that, these are the ones that in many ways we can actually do some work with, or if you can identify them, factors such as vision or whatever, you can refer appropriately to try and get something worked out, and so on.

So some of these intrinsic factors, as like I just said, vision is an important one so you need to make sure that patients have good visual acuity. So obviously things such as macular degeneration, cataracts, et cetera, in older populations are things that can obviously impair vision. So if they have those then obviously they need to be referred as appropriate onto practitioners to deal with that. You can also look at things like glasses. So [silence].

You may well find that they’re actually not aware of trip hazards in the environment because of the blurring effect that these multifocal glasses are potentially going to give them. So if they’re walking along an uneven pass, or there may be tree roots in a pass, or maybe some kids left a stick on the ground or something and grandma’s walking along and doesn’t see it because she’s got her multifocals on, that is a big thing where they can end up unfortunately making contact with the ground rather forcefully as a consequence of their vision.

Another thing that you can look at is visual contrast sensitivity. So what that becomes relevant for is things like seeing steps or seeing other trip hazards. If they’re low contrast trip hazards then you may actually have the situation where the older adult just will not see them, and therefore they’re more likely to fall over.

Now, the Neura Group out of Sydney have produced an app which allows you to assess visual contrast quite easily using an iPad. I think it’s only 50 bucks, or something like that, so it’s really quite cheap to bring into your clinic, and it will only take you a minute or two to evaluate that on your patients. And that can be something that you can identify as being an issue, and then you can refer to optometrists, et cetera, for further evaluation as needed.

Now, another thing you can actually do with vision is you can look at motion sensitivity. So the older adults will quite often be motion sensitive. One of the things that we know as they get older is that quite often, as they lose proprioceptive acuity and they also lose vestibular acuity, they will start to become very vision dominant in their attempts to maintain balance. And then when they become visual dominant, when they have visual field mismatches, such as, for example, standing next to a bus. You’ve probably all experienced this, that you stand next door bus and the bus starts driving off and you feel like you’re falling over because the bus all of a sudden starts to move. I’m sure you can imagine what I’m describing. If older adults have that visual field motion sensitivity it can compromise their balance and increase their risk of falling.

Now, one of the ways that you can do this is that you can present optokinetic stimulation to them, again using an iPad. And whilst it’s not the same as doing the full field optokinetic stimulation that some testing centres will do, for a clinic based situation that may well actually be quite satisfactory. So, that’s another thing that you can do with your older adults.

Things such as muscle strength obviously will affect balance, and therefore falls risk. So things like explosive power. Things such as just outright muscle weakness will compromise muscle strengths, and therefore the ability to correct from a fall quite often, or some sort of balance perturbation. So, testing your patient’s muscle strength and maybe even explosive muscle power. So things like vertical jump tests and so forth can give you a window to muscle strengths as well.

And one thing that I’m particularly interested in is looking at things like vibration sensitivity and touch sensitivity. So you can do things like just with a tuning fork you can assess vibration sensitivity. That’s very easily done within the clinic. And similarly, you can do touch sensitivity. So you can buy micro filaments which will do certain levels of light touch sensitivity. So usually 10 grammes of touch sensitivity is used, though I would potentially argue that we should actually be testing at a lower threshold in that even around four grammes or so to maybe potentially address earlier changes as part of our assessment of these patients.

And you can also do things like assess proprioceptive acuity as well. So one of the ways that we do this in our practise is that we will get the patient with their eyes closed. We will position one ankle in a particular degree of dorsi or plantar flexion, and then using an iPhone you can just use the inclinometers that you get on the iPhones, and you can measure the angle that that foot is sitting at. And then you get the patient and say to them, “Look, can you reproduce that angle in the other foot?” And you can use the iPhone to compare side to side and check the angle of inclination and so forth. So, it’s very easy to do with very low tech options within the practise. You don’t need to go out and spend thousands and thousands of dollars on high tech testing equipment to be able to do that.

Similarly, the balance evaluation scale is another way that you can actually assess balance within the practise, and they can give you objective measurements. Now, one of the things that we like to use when we’re assessing balance with our older adults, or in fact with all age groups, is stabilometry or posturography. Now stabilometry is something that you’re probably familiar with, even if you haven’t come across the term before. Most people will have used a Nintendo Wii balance board. And these balance boards basically use strain gauges, or there’s a number of ways that they do it depending on the technology that they’re using. But basically what is happening is that the board uses forces, or basically the forces generated by a person standing on the board, to measure what is known as the centre of pressure. Okay. And so that’s what this stabilometry is.

Now, the Wii balance board is, as I said, a very commonly available measure of that, and which has been shown to have quite good diagnostic accuracy. There’s certainly no harm in using the Wii balance board if you are doing balance assessments, particularly on a screening level. They’re quite good. The evidence suggests that that’s the case. There’s obviously much more high tech versions, things like Kistler plates, Bertec plates, Vestibular Technologies plates. There’s a wide variety of plates out there that you can get these days that you can use to actually quantify balance.

Now, what these plates do is that they measure the centre of gravity. Well, basically they say that they’re measuring the person’s centre of gravity, but in actual fact what’s happening is that they’re measuring the centre of pressure, which is a measurement which is extrapolated from the movements of the patient’s centre of gravity. And so basically, it’s the ground reaction force to the centre of force that is being applied by the person standing on the plate. Okay. Now hopefully that makes sense, but don’t get too hung up on it. And what you can then do is that you can actually do things like measure the speed of the movement of somebody’s centre of pressure. You can look at the root means square of deviations of the centre of pressure from the central or the mean measure of centre of pressure. So basically, you look at well, how far does the person sway? You look at how fast do they sway?

You can also do what’s called calculating a sway ellipse, which is predicted to contain 95% of the centre of pressure measurements. And so that can basically give you an area that you can then compare in pre and post testing and so forth. And these deviations, and velocities, and sway areas, and so forth, give you a quantification of a person’s balance. And these measures tend to increase as balance gets worse. So what we want to try and do is we want to try and do interventions with our patients to try and reduce the size or the magnitude of these sway measures. Okay.

So, that’s what I wanted to touch on this week within this podcast. As I said, this is our first episode. What we’re going to do next episode is I want to talk about a study which has actually been using centre of pressure from sway speed. And they’re looking at things like complexity of sway and how that correlates with balance and so forth, and some very interesting research about using sub sensory vibration to actually improve sway in older adults. And some really interesting stuff coming out around that where you can look at using vibration interventions to try and improve balance parameters.

So, we’ve touched on a lot here. We’ve talked about how there’s these obviously risk factors for older adults and how having these falls is really not a good thing for the older adults, how that increases their chances of moving into aged care, and mortality and so forth. We looked at environmental behavioural and intrinsic risk factors and how you might go about assessing some of those intrinsic risk factors. And then at the end here, obviously we’ve touched on using stabilometry to measure a person’s balance, using measures such as speed of sway, magnitude of sway, an area covered by sway and so forth.

So, hopefully you found that interesting. It’s something that we want to talk more about as we move along. I’d love to cover other topics, particularly to do with aspects such as management of neurological conditions in older adults. Or we’ve got some really great information I want to talk about, concussion management and so forth, as we move further along. We do a lot of vestibular rehabilitation and so forth in our clinics as well so I’m hoping that you’re actually going to find these very interesting. Let me know what you think, I’m very keen to know.

Okay. So thanks for listening to our podcast. If you are an Allied Health practitioner consider working for us at Focal Allied Health. New graduates and experienced practitioners are welcome to apply. Head across to focalhealth.com.au/careers for current positions. Alternatively, if you are a practice owner looking to exit your practice, contact us today about making your practice a part of our team. Head along to focalhealth.com.au/join.