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  • Dr. Doug Pooley

Come fly with me…because you sure as hell can’t walk.


“Walking mechanics as a predictor of disability and disease.”


If you have ever sat in a busy airport you know that the number one activity is people watching. Everybody does it and I am certainly as guilty as the next guy. There is kind of a sick sense of enjoyment derived from watching the chaos as people scramble towards their prescribed gate, often dragging luggage or children behind them. The looks on most faces is akin to attending a funeral while wearing tight shoes and suffering cramps. No one looks happy and everybody is in a rush. It can be a pretty macabre scene.


Normally, I just sit there like everybody else and marvel at the scene, but for whatever reason on my trip home last weekend, I started to watch people walk. I soon became fascinated by what I was observing. I could not get over the number of people in obvious distress as they moved along that corridor. Then as I looked a little closer I became startled by the number of people demonstrating abnormal gait patterns. What I mean here is shifts in their walking mechanics significant enough to be noticeable in casual observation.


Age had little to do with what I saw. Certainly the elderly demonstrated greater deviation, but readily observable changes were seen in all age groups and equally male and female.  As I continued to watch this flow of humanity moving in front of me it became evident that close to half of this sampling showed at least some deviation from normal functional walking mechanics. To the casual observer, the question would be—“So what?”  To me; my 40 years of treating the effects of postural deviation and the inevitable impact distortions in walking mechanics has on mobility and the breakdown of weight bearing joints set off a massive alarm.


It raised the questions: “What if this group I was observing was actually a reasonable reflection of the population as a whole? What would it mean if in fact a statistically significant percentage of us were distributing body weight abnormally or demonstrating perverse walking-mechanics? What would be the reasonable predictions for pain free mobility going forward?  At first blush, the natural response would be: “So what! …people are walking a little weird…everybody walks a little differently”. This is for the most part-true; we all have uniqueness’s in our gait due to body build, posture, injury, as well as a whole bunch of other uniqueness’s . Bottom line here though is that even subtle deviations over time will contribute to strain and eventual joint breakdown. Subsequently, it makes sense, that the more significant the deviations, the faster and more disastrous the consequences. It is just logical; the body is not unlike any other sophisticated machine with lots of moving parts. As long as the components perform in a balanced fashion in ways they were intended, the machine will keep on purring. Have just one part break down, and over time the end result is system failure. The same holds, true for the human body. Even with our tremendous capacity for self-healing, repeated insult over time eventually leads to injury and injury over extended periods of time creates impairment. Now, take this one step further and look at the consequences of restricted movement and loss of mobility on health. There is irrefutable scientific evidence demonstrating the relationship between mobility and health. Quite simply put, the more mobile you are, the greater the statistical likelihood of you staying healthy. This is not hyperbole, this is fact. There is plenty of evidence showing the impact mobility has on our ability to avoid and effectively fight disease. Documentation abounds on the impact of activity on everything from cancer to heart disease to impotence. There is substantial press these days on just the fallout associated with prolonged sitting over time to the point of being labeled—“Sitting is the new smoking!” Now, imagine a scenario of forced long-term immobility due to injury, and the disastrous implications to health. The following is a list of the most common negative impacts of immobility to health and is taken from “Complications from immobility by body system” LTC Clinical Pearls: Powered by HCPro's Long-Term Care Nursing Library, November 27, 2012.


Circulatory

  • Pooling of blood, reduced circulation, increased pressure on legs leading to blood clots.

  • Increased risk of edema.

  • Increased workload on heart.

  • Decreased blood pressure when resident gets up.

Endocrine

  • Changes in utilization of food leading to increased fat stores and glucose intolerance.

  • Increased insulin requirements for carbohydrate metabolism.

  • Changes in hormone balance.

  • Disturbed sodium-water balance.

Gastrointestinal

  • Risk for heartburn, indigestion, and aspiration due to positioning and inability to sit upright during meal and for one hour after meals.

  • Loss of appetite from reduced activity, depression, boredom, and illness.

  • May have impaired taste and smell due to aging changes or drugs. This further reduces pleasure of eating, increases loss of appetite, and reduces intake of fluids.

  • Weight loss and malnutrition from inadequate intake of nutrients.

  • Decreased peristalsis, decreased intake of fluids, and unnatural positioning for having a bowel movement using a bedpan promotes and contributes to constipation, impaction, nausea, vomiting, and ileus.

  • Difficulty pushing to eliminate stool when lying on back.

  • Digestive enzymes break down food. They will cause skin breakdown with prolonged contact with feces.

Genitourinary

  • Calcium drains from long bones, causing kidney stones and osteoporosis.

  • Position may cause difficulty voiding and inability to empty bladder completely.

  • Frequency of urination or overflow incontinence may occur.

  • Urine pools in bladder, increasing the risk of infection.

  • Skin contact with urine increases the risk of pressure ulcers.

Integumentary

  • Heat, pressure and reduced oxygenation of skin increases the risk of pressure ulcers.

  • Healthy adults normally change positions approximately every 11.6 minutes during sleep. The inability to reposition independently further increases pressure ulcer risk.

  • Friction and shearing during movement promotes abrasions, skin injuries, and breakdown, leading to pain, infection, and other complications.

Muscular

  • Often the first system to show the effects of immobility; reduced muscle mass, strength, and oxidative capacity.

  • Muscles begin to feel stiff and sore on movement; movement progressively becomes more difficult.

  • Muscles weaken and atrophy. Most prominent problems usually affect muscles associated with ambulation and upright posture.

  • Resident loses up to 7% to 10% of strength weekly.

  • Immobility and disuse of muscles in abdomen and spine combined with uncomfortable positioning and aging changes may cause low back pain.

  • Contractures may begin in as little as four days. Range of motion is lost by day 14 or 15.

  • Contractures complicate care and cause pain.

  • Contractures cause capillary occlusion at bony prominences, contributing to pressure ulcers. As much as 50% to 70% of all pressure ulcers are related to untreated contractures.

Nervous

  • Weakness, loss of independence, and limited mobility may cause depression, anxiety, restlessness, irritability, boredom, apathy, disorientation, passive-aggressive verbal and nonverbal communication, mood swings, listlessness, withdrawal, social isolation, regression, altered body image, and feelings of helplessness.

  • Lack of stimulation and social isolation increases the risk of delirium and disorientation.

  • The resident may sleep during the day and be unable to sleep at night.

  • Alterations in the sleep pattern may cause dissatisfaction, disorientation, and inability to participate in therapeutic programs and care during the day.

Respiratory

  • Difficulty expanding lungs fully/taking a deep breath due to position.

  • Weight of chest further limits lung expansion in large residents.

  • Cough weakens, reducing ability to clear secretions.

  • Retained secretions remain in airway, causing collapse of alveoli.

  • Ability to exchange oxygen and carbon dioxide is impaired, causing under ventilation and inadequate oxygen level in blood (hypoventilation and hypoxemia).

  • Difficulty taking a deep breath causes anxiety and may result in dyspnea.

  • Blood redistribution and fluid shifts increase the risk for pulmonary edema and blood clots.

  • Pooling of secretions increases the risk of pneumonia and lung infections.

  • Deaths have been reported when secretions block the airway

Skeletal

  • Calcium drains from long bones due to immobility.

  • Immobility and decreased weight bearing cause hormone imbalances.

  • Risk for osteoporosis, pathologic fractures of the vertebrae, hips, pelvis, and shoulders is increased.

Pain

  • The physiological changes associated with immobility start to show up almost immediately.

As a health care practitioner, I was floored by the above list of potential side effects of loss of mobility. I realize that this list is in reference to more complete loss of mobility, but it is not difficult to draw a line between efficiency of movement and its impact on disease.

It occurred to me while I was sitting in that airport observing humanity as it passed by that nobody in health care really looks at how we walk and certainly not at all at the ramifications over time of faulty walking mechanics.  As health care providers, we have been so conditioned to treat symptoms and rely on prescribed tests and procedures to make a diagnosis that we have lost the enormous health care potential of simple observation. We acknowledge the importance of prevention, but have again lost perspective as to what prevention really means especially when it comes to our understanding of the evolutionary expression of a 21st century human being.  Evolution has genetically engineered us to be magnificently efficient movement machines with every neuro-bio-chemical function of the body being influenced by the quality and quantity of that movement. The simplicity of observation as a diagnostic tool for functional mechanical evaluation of the body during movement should be a primary preventative procedure and performed routinely like dental check-ups. This is especially true for our youth. From a purely pragmatic perspective, this is the only sub-section of society that we can hope to functionally impact. This is the group where there is still a measure of control and containment sufficient to impact physical growth, structural integrity and habit. If we do not start here, within the space of less than one generation, the potential for predictive disability with all the spin-off costs associated with an increasingly dysfunctional society will far overburden our collective ability to cope with the weight of the health care expense. Not wishing to be a fatalist, you do not have to look much beyond the apparent to appreciate the ultimate costs to industry, government and society as a whole.


The Take Away:
  • Pain free and efficient walking mechanics is pivotal to mobility.

  • Compromised mobility will eventually lead to pain and disability

  • Causes of most alterations in walking mechanics can be identified and corrected if found early enough.

  • Periodic mobility checkups with your chiropractor just make sense at any age but especially during growth.

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