Interviews conducted and edited by Frank Long, MS, Editorial Director, Physical Therapy Products
Becoming deconditioned is a possibility for everyone. Older adults, not surprisingly, comprise the greatest percentage of what is known as “hospital-associated deconditioning,” but younger people and athletes can be adversely impacted by the effects of deconditioning as well. We asked three physical therapists who direct care for deconditioned individuals to explain how they approach treatment for this patient population, and to share the go-to technologies they use for restoring strength and endurance. Here is what they had to say.
Good Things Come to Those Who (Un)Weight
The Physical Therapy & Wellness InstituteMulti-office practice headquartered in Lansdale, PaMark Romano, DPT, discusses how to get deconditioned patients accustomed to walking without using their full body weightDefining “Deconditioned”
In a nutshell, a deconditioned person is anyone who has difficulty walking household distances and community distances—not due to pain but due to being deconditioned. If someone can’t really walk 500-600 feet without taking a rest break, that would be more of a community distance; 150 feet would be considered a household distance.
A person who is significantly deconditioned probably has cardiovascular deficiencies, so getting endurance training back into them is vital. Whether it’s doing a bike—even doing arm bike—it’s critical just to get their bodies working for 10 minutes at a time.
Our practice, which has nine locations in Pennsylvania, has several AlterG Anti-Gravity Treadmills, and more often than not this is the technology I use with deconditioned patients at the Glenside site. It’s a normal-functioning treadmill that encloses the user into an airtight seal and allows the therapist to take off up to 80% of the patient’s body weight. That way, the patient can work on walking for 10, 15, or 20 minutes and get their bodies used to walking even though they’re not using their full body weight.
The Anti-Gravity Treadmill inclines like a normal treadmill, so you can strap in the patient facing forward or facing backwards. You can also strap in the person facing sideways and work on lateral side-to-side movements. You can target different muscle groups such as the side of the hips or if you’re working on the back of the hips, the glutes, things like that. And, based on how the patient is presenting, you can get creative with that positioning.
Dosing from patient to patient is based on how the person presents and where they are in that deconditioned state. So, on my first-session evaluation I’ll do a walking test and maybe the person can only go for 400 feet in 6 minutes; I’ll use those parameters for the treadmill. There’s also a little bit of test and re-test involved in getting the dosing right, and we can adjust the body weight percentage, walking speed, and incline as the person progresses. Deconditioned patients usually start off on the AlterG, and as they progress we transition them to a conventional treadmill.
There’s not much of a learning curve for this device, but what’s important is for therapists to try it out themselves and see what it feels like to have a certain percentage of body weight taken off. Deconditioned patients are not used to a lot of activity, so it’s up to us as therapists to really push them and know how the experience feels.
This is the first piece of technology I’ve seen that is considered offloading, or unloaded. In terms of unloading, a key difference between the Anti-Gravity Treadmill and aquatic therapy is that aquatic therapy facilitates an unloaded type of exercise therapists can use to decrease body weight and build muscle activity and strength. What we are trying to do with the Anti-Gravity Treadmill is different. We are trying to retrain a person how to walk, which is not something you can really do properly in the water. The Anti-Gravity Treadmill allows you to take off the proper amount of body weight and work on the proper mechanics to get someone used to actually walking.
Safety and a Challenge
Peak Physical Therapy & Sports Performance. Multi-office practice headquartered in Norwell, MassWhen purchasing endurance equipment Eric Edelman, PT, finds that “fancy” takes a back seat to safety and reliabilityFunctioning Below Capacity
When we say “deconditioned,” we generally refer to someone who is not up to their optimum endurance and strength. They may have an underlying disease, mobility issues, or had a lengthy hospitalization. There may be a pulmonary issue that is causing them to be deconditioned. In general, someone with a lack of endurance, lack of strength, and most importantly from the way we look at it, an inability to function at their maximum capacity.
Goals Guide Therapy
Regardless of whether you’re setting up a therapeutic conditioning program for an elderly person or a high school athlete, success hinges on doing a proper evaluation and determining what the patient’s goals are. An 80-year-old, for example, will want to be able to get up out of a chair and get to the bathroom; maybe go to the grocery store or play with grandchildren. Those tend to be lower-level goals compared to the athlete who wants to get back to sport. We have an entire return-to-play program to address that. At one of our sites we’re inside of a sports complex, so we’ve got access to turf and hard courts. So those athletes, by the time they’re getting their strength and their range of motion back, the therapist is taking them out to the turf or the hard courts and simulating the patient’s sport.
For the elderly person, there’s just walking. We have to increase their walking distance, so we’re practicing that. If they need to do stairs, we’re practicing stairs. If we need to get them out of their chair, then we’re practicing squats. It’s a lot of general strengthening, and we use weights and the full spectrum of equipment, but we’re actually going to perform some of those activities and simulate them to strengthen the body in the best way possible.
Endurance at Ground Zero
To get people started on working on their endurance, oftentimes we will use recumbent bikes and several types of treadmills. We have a sports performance treadmill, The S-Drive by Matrix Fitness USA, (Cottage Grove, Wis) that we use for athletes; it allows them to simulate parachute-type running with resistance, or getting into a position that simulates prowler sled pushing. Or, you can just vary the resistance. It’s on a slight incline, and it’s self-propelled. For our elderly patients we would use a standard type of treadmill to slowly increase their speed and the time that they’re spending on it. We also have a recumbent bike that I’d count among our go-to gear. Also, if it’s an upper body issue, we have upper body ergometers (UBE). The UBEs are great if a person has an upper body issue, but even if they have a lower body issue—for example, they can’t tolerate moving their legs a lot—we can get their heart rate up by having them use a UBE.
Building a Winner
When I purchase equipment it has to be done strategically because of the heavy competition we face. Our practice consists of four “standard” offices as well as a separate women’s health center and off-site aquatics. Chiropractors give us competition as well as other outpatient practices and the local hospital’s clinic.
When I make an equipment purchase, the number one qualification is safety. It’s also important that a device has features that allow you to make adjustments to challenge the patient. For example, all the treadmills and recumbent bikes have different programs that are helpful for improving endurance or improving strength, such as allowing the user to vary the terrain. And, while options like that are always nice, the fact is that equipment doesn’t need to be terribly fancy for me to buy it. It needs to be reliable and safe, and perform the basics that our therapists and patients need to get the best outcomes.
What Else Can We Do with This?
Oceanside Physical Therapy Inc, Stuart, FlaBryan Graham, MPT, finds hidden performance in equipment that provides big returns when working with deconditioned patientsCompetitive Landscape
During our season we have a geriatric caseload that comes in but my office is in kind of a predominantly sports medicine office, so even a lot of the geriatric patients who come in are typically active people: they golf and play tennis and pickleball—which seems to be the new thing. We also have high school and middle school athletes who are coming in with ACL injuries or shoulder problems.
A big group of patients we see are hip labrum repair: young athletes, dancers, soccer players all the way through college, and typically a younger clientele into their 40s and 50s. You want to talk about deconditioned? These patients typically take more than a year to get properly diagnosed, so oftentimes they’re coming in severely weak on the side that is affected and they’re not exercising anymore.
Two Approaches to Conditioning
Getting a geriatric patient back to the level of conditioning they need is a different ball of wax from getting a young athlete back to the level of conditioning they want. For example, we had a youth athlete who was a soccer player preparing for preseason and she had to be able to do 10 100-yard sprints in a certain amount of time. So we had her on our Woodway Force manual treadmill—which has a loaded belt—doing 10-second sprints trying to re-establish her sprint endurance. Obviously, I’m not putting a 70- or 80-year old patient on that equipment.
For the elderly patients I’m going to put them on a recumbent bike or have them on the AlterG Anti-Gravity Treadmill where I can use reduced weight-bearing. Reduced weight-bearing takes away pain, any stress on the joint, or anything that is postsurgical. It also reduces the patient’s body weight, which then reduces the cardiac demand and the endurance demand. You can take an older patient who is deconditioned after a hip replacement and put them in the AlterG and get them back to walking and developing a normal gait, but also help them build up their endurance to return to normal community walking distances.
Actually, I bought the Anti-Gravity Treadmill with the running community in mind to provide them the ability to maintain running while injured. However, we quickly learned about other things it could do, such as giving a deconditioned patient the ability to lose some weight and gain some strength prior to surgery. We put that same person in the AlterG, reduced their body weight, and now they can exercise to shed weight and build some strength.
We have a variety of technologies to get people back into condition, including a StairMaster Gauntlet StepMill and a VersaClimber. The VersaClimber can be helpful for clients who are firefighters and need to be able to climb ladders and things like that, the Force treadmill. We have a slew of stationary bikes, which is something for your really deconditioned geriatric patient. The bikes can provide a “starting phase,” to get them going, but oftentimes they mainly are just warm-up tools.
Do the Homework Before You Buy
I don’t buy equipment just to buy it. I research it, see where it’s going to fit, and look at different ways that we can utilize it. Durability and versatility are big factors. The VersaClimber and StairMaster Gauntlet have great durability, and you can extrapolate them to a lot of different activities. For example, just climbing the stairs on the StairMaster provides a lot of options for random function that can mimic the demands of soccer or hockey. It replicates the motion of lifting the hip up for running, it helps redevelop the quad and glute strength needed for pushing and propelling an athlete while they are running. Even the VersaClimber, when the user is using the hands and legs, that’s creating similar respiratory demands that you might have if you were a swimmer.
The best way I’ve found to get the greatest return on a piece of equipment is to turn my therapists loose on it and say, “Figure out what else we can do with this. Where else can we be innovative?” Once you start doing that, you get more patients on them and they pay for themselves. PTP