By Polly A. Swingle, PT, GCS, CEEAA
At a time when people are living longer, generally healthier lives, geriatric therapy has emerged as an increasingly critical therapeutic specialty—particularly given the fact that surgical remedies for chronic pain and debilitating injuries have made enormous strides in recent years. Today, patients routinely receive joint replacements that allow them to return (at least in the vast majority of cases) to a vigorous and active lifestyle. But geriatric therapy is not just a vital component of recovery from orthopedic injuries and surgical repairs and replacements; it is also a proven way to slow and delay the toll that aging takes on the body. The right therapeutic approach with a trained professional can make an extraordinary difference in an aging patient’s mobility and overall health and well-being.
The term “geriatric” actually refers to anyone over the age of 60 years, but in the context of longer life expectancies (what was not too long ago an average life expectancy in the early 70s has increased to the late 70s and even early 80s for many demographic groups), medical and therapeutic professionals often think about geriatric patients in two sub-categories: ages 60 to 75 years, and ages 75 to 98+ years.
Whether a geriatric patient has experienced a joint replacement and needs to strengthen the joint and corresponding muscles, or whether he or she simply needs to improve strength, flexibility, and balance to continue enjoying a healthy and appropriately active lifestyle for as long as possible, geriatric therapy can have a positive and potentially transformative impact.
The key to maximizing the benefits of that therapy is not only understanding the basic tenets and techniques of a sound therapeutic program, but also appreciating common obstacles and how to overcome them.
Physiological Changes of Aging
As we age, all of our systems start to change. The cardiovascular system becomes less efficient, with decreased cardiac output, an increase in heart rate and a corresponding decrease in maximum heart rate, a lower O2 maximum, and general increases in rates of hypertension (high blood pressure).
The musculoskeletal systems also begin to wear down. Fewer new muscle fibers are produced as humans age, and oxygen and energy delivery systems begin to degrade. The result is that we become physically weaker. Humans also become more frail as the bones become more porous and bone mass is lost. Consequently, geriatric patients are at a higher risk of bone fracture.
Neuromuscular changes include decreased postural control, slower overall movement, worsening balance and agility, and significantly reduced reflexes and reaction time. That constellation of symptoms diminishes the ability to respond to a lack of balance, and the frequency of falls and other accidents increases. Mental health declines as aging occurs, leading to memory issues and generally more sluggish cognitive performance.
The good news is that the right exercise program—designed specifically for geriatric patients—can slow or reverse many of those declines. Geriatric therapy can lower blood pressure and lead to more efficient cardiac performance. It can increase production of type 2 muscle fibers, leading to an increase in overall muscle size and strength, as well as increased bone mass. Neuromuscular changes in response to exercise include increased postural control and speed of movement, fewer falls, and an increase in proprioception and gait velocity. The positive impacts of exercise on endocrine health include decreased insulin resistance and a corresponding decrease in the risk of developing type 2 diabetes, and increased levels of serum growth hormone and testosterone. Mental health benefits are extensive, and include (but are not limited to) increased self-respect and decreased anxiety and depression.
Common Diagnoses of the Elderly
Common diagnoses among geriatric patients include: Alzheimer’s and other cognitive impairment; arthritis and other degenerative joint and musculoskeletal conditions (osteoarthritis is the number one cause of joint replacement in knees and hips—and almost everyone by age 70 years has some degree of osteoarthritis in their joints); congestive heart failure and other cardiac conditions like post-heart attack fatigue and breathing problems; chronic obstructive pulmonary disease (COPD), other obstructive lung disease, and lung cancers—common among smokers and those exposed to secondhand smoke; depression, which can contribute to an isolated and sedentary lifestyle that hastens physical deterioration; diabetes, especially type 2 diabetes, which is caused primarily by diet and lifestyle; and orthopedic problems such as back and shoulder pain, osteoporosis (especially among women), and fractures as a result of falls. Comorbidity is also on the rise.
Therapeutic Programs and Prescriptions
The right geriatric physical therapy program can help mitigate the impact of all of those. Here are some specific programs and protocols for some of the most common geriatric diagnoses:
Exercise is critical to controlling high blood pressure—even more so than medication. Endurance exercise will elicit an average reduction of 10 mmhg for both systolic and diastolic blood pressure.
A sample prescriptive exercise program might include:
- Daily aerobic activity, between 30 and 60 minutes at moderate intensity.
- Resistance training (weight lifting, body bands, or body weight exercise like yoga). Include one set of eight to 12 repetitions, two to three times per week at 60% to 80% of your one-rep maximum.
- A minimum of 10,000 steps per day, which is the target to achieving health-related benefits. (Note that anything less than 5,000 steps per day is considered to be a sedentary lifestyle.)
- Exercise should not be performed if systolic blood pressure is greater than 200 mmhg or diastolic blood pressure is greater than 110 mmhg.
- Always include a gradual cool-down period after exercise, especially if the patient is on beta blockers and/or other blood pressure medication.
Peripheral Vascular Disease
Peripheral vascular disease is associated with impaired sensory and motor skills. Exercise can help increase circulation, improve exercise tolerance, and enhance walking ability. An exercise program for geriatric patients suffering from peripheral vascular disease might include:
- Weight-bearing aerobic activity 3 to 5 days per week at moderate intensity for 30 to 60 minutes per day. Patients can and should be allowed to walk until pain decreases sufficiently for them to increase activity.
- Resistance training two times per week.
- Resistance training three times per week.
Total Knee Replacement
Approximately 700,000 individuals receive a total knee replacement every year. The average patient achieves 90% recovery after 3 months of postop therapy, and it typically takes 6 months or longer to get to 100%. The average age of a total knee replacement patient is 70 years, and 60% of those patients are women. Total knee replacements today can be expected to last approximately 20 years.
It takes regular exercise to restore full strength and mobility to the knee after a total knee replacement. The current recommendation is 20 to 30 minutes of exercise per day (for 2 to 3 days per week during the early portion of the recovery). Treatment evidence shows that balance training is important to help decrease falls, neuromuscular electrical stimulation (NMES) and aquatic therapy can be very helpful, and there should be an general emphasis on quadriceps strengthening. Evidence shows that intensity must change daily to ensure maximum therapeutic response.
Additional tips and best practices include:
- Keep it smooth
Walk as rhythmically and smoothly as possible. Holding something in the opposite hand (a can of food, for example) can help balance and smooth out gait.
- Get out of the house
A recent study suggested that when it comes to results, patients who undergo total knee replacement and engage in home physical therapy before participating in an outpatient physical therapy program ultimately wind up doing just about as well as the patients proceeded directly to outpatient therapy sessions. In fact, for some metrics, patients who proceed directly to outpatient therapy (a typical outpatient therapeutic schedule is two to three sessions per week for 4 to 6 weeks) actually improve slightly faster.
- Start early
Evidence shows improvement in postop recovery with improved preop performance of functional tasks. Patients scheduled for a total knee replacement would be wise to go in for a quick session or two before their surgery (insurance permitting) to learn how to correctly use a walker, get in and out of bed, and perform other basic tasks and movements.
- Both sides matter
Evidence shows that the nonsurgical “healthy” knee is also at risk of needing total knee replacement, and, for reasons of balance and future health, that joint should not be neglected during postop therapy.
Total Hip Replacement
Around 500,000 patients receive a total hip replacement annually. In general, hip replacements are much easier to rehabilitate than knee replacement, and the expected recovery time is around 4 to 6 weeks.
Although the focus for a hip replacement recovery is more about strengthening and balance and not so much on range of motion, many of the same therapeutic principles apply. It should be noted, however, that there are currently two different surgical approaches to total hip replacements (posterior and anterior), and therapeutic priorities and limitations will differ depending on which technique has been utilized.
In addition to aerobic and resistance training, a general geriatric physical exercise prescription should also include flexibility stretches and exercise 2 to 7 days per week for all major muscle groups, gait locomotion training for 5 to 7 days per week (varying the intensity). Keep in mind that a warm-up/cool-down period is particularly critical for geriatric patients. Like an older car in the winter, you can’t just gun it or it will seize up and stall. Finally, all therapeutic programs should adhere to the basic principles of exercise, specifically the importance of intensity (self-explanatory) and specificity (to get better at a specific task, the therapeutic program should include that specific task).
Therapists who have the responsibility to restore functional ability and rebuild strength and endurance among older adult patients recovering from joint replacement have an array of tools available to tailor exercise programs in the clinic and home. Treadmills are a staple in many clinics for helping geriatric clients ease back into walking, and the market offers several models engineered especially for the medical and physical therapy market, such as the T635M Treadmill from SportsArt, Mukilteo, Wash.
The T635M has features such as extended handrails that are useful for rehab patients, as well as deck cushioning designed for excellent shock absorption and the ability to move in reverse up to 3 miles per hour. Another source, Exertools, Petaluma, Calif, offers the BH LK Series Treadmills with medical rails option. The BH LK 700Ti is built with an orthopedic cushioned belt, Quick Speed and Quick Incline Keys, and a two-speed cooling fan. Several models of SportsArt Medical Treadmills are also available through Exertools.
Elliptical trainers are also clinic-based equipment that can be useful in providing low-impact therapeutic cardiovascular training. For example, Precor, Woodinville, Wash, manufactures the EFX 833 elliptical with a ramp that inclines from 10 degrees to 35 degrees, and provides 20 levels of resistance. It is also engineered to provide the user a natural converging stride path. Exertools also offers a range of elliptical technologies, including several models from SportsArt and commercial models from Spirit Fitness and BH Fitness.
After total knee arthroplasty patients may benefit from a variety of activities that use elastic bands or tubing to perform a variety of activities that address pain symptoms and flexion, or build strength. Likewise, prior to surgery, a program of “prehabilitation” may be appropriate for some patients. Some of the associated exercises that may be beneficial for those patients include kick backs in standing, kick outs, knee curls, squats over a chair, and performing hip flexion while seated in a chair.
There are several sources for these products in the physical therapy marketplace, including Warminster, Pa-headquartered Stretchwell Inc, which offers the Fit-Lastic line of progressive resistance therapy products. This line includes therapy bands and tubing that create several levels of resistance and are identified by color. Exertools, too, provides a number of therapeutic resistance brands, including flat bands that are color coded from Champion Sports and Lifeline Fitness. Exertools also offers the ExerTube line of resistance tubing with a range of resistance levels and fixed handles. The Exertools MAT Tubing System allows the user to use the tubing with door jambs, doorknobs, and around poles. OPTP, Minneapolis, also offers a variety of elastic exercise products, including Thera-Band loops and tubing.
Medication Effects on Exercise
Because geriatric patients are more likely to be taking medication, understanding some of the common side effects of popular medications—and their potential impact on a patient’s ability to exercise—is an important part of designing a safe and successful geriatric therapy program. The most common side effects of many popular medications are dizziness, light-headedness, and fatigue, but specific side effects that need to be considered include the following:
- Anti-hypertensives: orthostatic hypotension and muscle spasms and cramping (Avapro, Cozar, Benicar).
- Anti-arrhythmic agents: swelling in feet/ankles, altered heart rate.
- Beta blockers: reduced heat tolerance, premature fatigue, reduced time to claudication (pain caused by a lack of blood flow during exercise). Patients taking propranolol or atenolol should limit their exercising heart rate to 20 BPM over their resting heart rate.
- Calcium channel blockers: swelling in ankles, altered and altered heart rate (Cardizem).
- Digitalis: gastrointestinal distress, blurred vision, depression, and fatigue.
- Statins: reduced cholesterol can lead to faster onset of claudication, leading to muscle soreness and weakness.
- Anticoagulants: dizziness, headaches, and stomach upset.
- Antidepressants: orthostatic hypotension, increased heart rate, and arrhythmia.
- Anti-dementia medications: nausea, weight loss, muscle cramps, and depression.
Barriers to Effective Exercise for the Elderly
Understanding the most common barriers to effective exercise for geriatric patients is just as important as understanding the exercises themselves. It doesn’t matter how good your technique is if the patient doesn’t follow through. The most common barriers and objections include:
- Lack of knowledge
- Lack of time
- Lack of energy/motivation (with a direct correlation with depression)
- Don’t like doing it alone
- Lack of resources
- Fear of falling
- Personal beliefs
- Older age
- Decline in cognition
- Negative attitude
- Care-giving responsibilities
One way to break through those barriers is to introduce geriatric patients to increased levels of physical exertion through group/social activities such as walking groups, yoga classes, tai chi, dance, or aquatic exercise programs. All of these are (to various degrees) low- or no-impact, and all can help with strength, flexibility, and cardiovascular health. Doing something social and not traditionally perceived as “therapy” can get the endorphins flowing, give patients the energy and optimism they need to continue, or even increase their exercise program.
For geriatric individuals, that means (hopefully) avoiding the increased disability, decreased mobility, functional decline, and decreased social activity that comes with age, isolation, and inactivity. And, whether recovering from surgery or simply looking to extend and improve the quality of life, those are worthy goals indeed. PTP
Polly A. Swingle, PT, GCS, CEEAA, is co-founder and lead physical therapist of The Recovery Project, which provides progressive, effective, evidence-based neuro rehab therapies that improve the quality of life and functionality of patients with spinal cord, neurological, and traumatic brain injuries at its three Michigan-based locations. For more information, contact [email protected].