Scientists estimate that humankind has been walking on this earth for more than 200,000 years. The bipedal stance and gait that we use are an efficient and elegant means to ambulate. As the life expectancy of people in this country has increased by over 30 years since 1900,1 we have observed a direct correlation between inefficient gait patterns and degenerative changes in the lower extremity and spine.
According to the article “Prevalence of Total Hip and Knee Replacement in the United States,”2 the prevalence of total hip and total knee replacements in the US population in 2010 was 0.83% and 1.52%, respectively. Prevalence was higher among women than men and increased with age, reaching 5.26% for total hip replacement and 10.38% for total knee replacement at 80 years old. These estimates corresponded to 2.5 million individuals (1.4 million women and 1.1 million men) with total hip replacement and 4.7 million individuals (3.0 million women and 1.7 million men) with total knee replacement in 2010. Secular trends indicated a substantial rise in prevalence over time and a shift to younger ages.
It concludes that around seven million Americans are living with a hip or knee replacement, and consequently, most are mobile, despite advanced arthritis. These numbers underscore the substantial public health impact of total hip and knee arthroplasties. The incidence of joint replacement procedures is high, with over one million total hip and total knee replacement procedures performed each year in the US.3 With the aging of baby boomers, higher rates of diagnosis and treatment of advanced arthritis, and growing demand for improved mobility and quality of life, the annual procedure volumes are projected to increase considerably in the future, making joint replacements the most common elective surgical procedures in the coming decades.4-5
Such a large increase in demand is unprecedented and must be addressed with effective planning of healthcare services for these individuals, not only during the perioperative period but throughout the lifelong continued care of this population.
The Chiropractor’s Role
Where do chiropractors fit into this effective planning of healthcare services for these people? In my opinion, we have an opportunity to create a positive influence decades before the degenerative changes have advanced to a point requiring medical/surgical intervention. We need to give attention to proper posture, gait, and functional movement and intervene with appropriate treatment that, in addition to chiropractic manipulative therapy, may include rehabilitative exercises, soft tissue treatment, and gait training with the use of foot orthotics.
The walking gait is a daily, repetitive source of biomechanical and physiological stress on the body. In a paper titled, “Impulsive Forces During Walking and Their Clinical Implications,”4 it states that “during normal walking, repetitive impulsive forces are introduced into the musculoskeletal system. At heel strike, there is a sharp irregularity in the ground reaction force, known as the heel strike transient. As a result of experimental evidence indicating possible correlations between impulse loading and joint degeneration, research interest in heel strike transients has intensified.” This paper outlines the nature of the heel strike transient and the use of accelerometers and force platforms for skeletal transient investigation. Attention is given to two experiments that analyzed the response of the human body to the impact forces experienced during walking. The possible causative links between excessive impulsive loading and the progression of two pathological conditions — osteoarthritis and low back pain, respectively — are discussed in detail. The link to the pedal foundation and the number one reason patients seek treatment from a chiropractor is well established. We need to do a better job of evaluating the feet and their possible influence on pain and the degenerative process.
...“We need to do a better job of evaluating the feet and their possible influence on pain and the degenerative process.”...
The biomechanical link to inflammation and tissue degradation has been observed in clinical practice for many years, but it has also been observed in research settings. In the paper “Bone Marrow Edema Caused by Altered Pedal Biomechanics,”6 Dr. Terry Yochum and Dr. Mike Barry linked the physiological response of bone marrow edema to excessive pronation of the foot in a patient that was a runner. The biomechanical stress of pronation with activity creates an inflammatory response that, if left to persist, begins to create a breakdown at the cellular level, which can cause a failure of the tissue resulting in a sprain, strain, tendonitis, tendinopathy, or stress fracture.
These stress responses in the joints contribute to the chronic degenerative changes we see with age. It is an insidious process that is characterized by gradual changes in gait, balance, and flexibility with episodes of pain that are often addressed with home-based remedies or brief symptom-relieving clinical care. The pitfall of episodic symptomatic care is the failure to address the structural asymmetries that exist because of a compromised pedal foundation due to excessive, asymmetrical pronation of the feet, which are clearly linked to low back pain and osteoarthritis.
A responsible approach to addressing the biomechanical cause of pain and degenerative arthritis in the lower extremity and spine is to intervene with a stabilizing three-arch custom orthotic that addresses heel strike shock and its correlation between impulse loading and joint degeneration.
Shock absorption is important, but efficient neuromusculoskeletal responses to orthotics are also critical. Many generic soft orthotics on the market create a comfortable cushion for the foot but do not enhance the sensory-motor reflex between the three arches of the feet, which engage postural tone and enhance muscular performance. Off-the-shelf soft orthotics allow the excessive pronation of the foot to persist, creating the same biomechanical stressors on the knees, hips, pelvis, and spine.
Creating a treatment plan for our patients that will address the negative effects of gait-induced shock force, the resulting inflammatory response that can lead to bone marrow edema, and degeneration of knees, hips, and spinal joints is easier now than ever before. Digital laser-scanning technology, along with technological advances in synthetic high-performance shock-absorption materials and fabrics, are available to our patients, creating the consistent protection of the spine and extremities while enhancing balance, flexibility, and safe, functional movement.
As chiropractors, we do play an important part in the effective planning of healthcare services for all our patients who desire to preserve healthy joints and mobility and avoid the possibility of future treatment of advanced arthritis.
References:
1. Crimmins EM. Lifespan and Healthspan: Past, Present, and Promise. Gerontologist. 2015;55(6):901-911. doi: 10.1093 gerontgnv 130
2. J Bone Joint Surg Am. 2015 Sep 2; 97(17): 1386-1397. Published online 2020 Jan 1. doi: 10.2106/JBJS.N.01141 PMCID:
PMC4551172 PMID: 26333 733
3. Kurtz SM, Lau E, Ong K, Zhao K, Kelly M, Bozic KJ. Future young patient demand for primary and revision joint replacement: national projections from 2010 to 2030. Clin Orthop RelatRes. 2009. October;467(10):2606-12. Epub 2009 Apr 10. [PMC free article] [PubMed] [Google Scholar]
4. Cram P, Lu X, Kates SL, Singh JA, Li Y, Wolf BR. Total knee arthroplasty volume, utilization, and outcomes among Medicare beneficiaries, 1991-2010. JAMA. 2012. September 26;308(12): 1227-36. [PMC free article[ [PubMed] [Google Scholar]
5. https://www.chnbiomech.com/art... Pdf
6. https: Zpubmed.ncbi.nlm.nih.gov 9004123
jgflfet Dr. BrianJensenisagraduateofPalmerChiropractic College and owner of Cave Spring Chiropractic 'n R°an°ke' Virginia. He has been in practice for over 31 years. As a member of the Foot Levelers A\ mm Speakers Bureau, he travels the country sharing his ■ knowledge and insights. See continuing education seminars with Dr. Jensen and other Foot Levelers Speakers at footlevelers.com/continuing-education-seminars.
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