105 12 Physical Therapy Management of Select Rheumatic Conditions in Older Adults
compressive forces on the spine; thereby increasing its cross- sectional diameter. Unfortunately, this mode of exercise is available only in the clinical setting. Stationary cycling (either recumbent or traditional seated posture) places the spine in a flexed position and is well tolerated and proven to enhance aerobic conditioning, strength and mood [18].
Manual therapy, in the form of manipulation or mobilization, can be used to restore normal range of motion and when fol- lowed by lumbar stabilization exercises, to enhance function [21]. Spine mobility can be improved by stretching tight structures such as hip flexors, adductors, and myofascial tis- sues. Postural education reinforces spinal alignment during exercise and with activities of daily living. Aquatic exercises minimize stress on the spine and the buoyancy of the water can facilitate motion [22]. Table 12.2 summarizes studies of physical therapy intervention for LSS [18, 23–27].
The Maine lumbar spine study [28] assessed the 4- and 8-to-10-year outcomes of surgical and nonsurgical treat- ments for patients with LSS and demonstrated that patients treated nonsurgically reported decreased back and leg pain.
There was no detailed description of therapeutic exercise included in the report. Published reviews of clinical trials of exercise interventions for nonsurgical management of LSS indicate variable effectiveness [20–22, 28].
in costs are expected [29]. Approximately one-quarter of older adults who sustain a hip fracture experience permanent loss of independence and 15–25% die in the following year [29]. Medications can decrease fractures in at-risk patients by 40–50% when used as prescribed [30]. However, few patients use their medications regularly [31]. Many fractures could be avoided through preventive measures, such as earlier imple- mentation of physical therapy to address physical impair- ments and factors associated with fall risk, coupled with targeted use of effective pharmacotherapy.
Physical Examination Findings and Interventions
Typical history and physical examination findings include: a history of smoking; early menopause ( age <45 years); dimin- ished height, slight build; kyphosis, flatten lumbar curve, tight shoulder, hip and leg muscles, muscle weakness, reduced aerobic capacity and diminished balance. Table 12.1 summa- rizes clinical features and physical therapy interventions [9].
Physical therapy can be provided as primary prevention or as a tertiary intervention. The primary goals of physical therapy are to reduce fracture risk, maximize strength, improve balance and function, and ultimately maximize independence. Interventions address posture alignment and re-education, strength, flexibility, core stability, function, home safety, and independence in activities of daily living and ambulation. As always interventions are directed by the physical examination findings.
Physical therapy interventions are directed towards decreasing bone loss rather than increasing bone mass [32, 33]. Various studies have shown that a combination of exer- cises with supplemental calcium and vitamin D is more effective in reducing bone loss than exercises alone [34, 35].
The effects of exercise on BMD are reversible and progres- sive exercises are more effective than nonprogressive exer- cises in maintaining BMD, hence regular follow-ups and progression of exercises should be performed [35–37].
Research studies [35–39] indicate no significant differ- ences in outcomes using high and low impact aerobic exer- cises, however, low impact aerobic exercises are typically safer and better tolerated in older adults. Very high impact exercise and extreme ranges of motion should be avoided with the frail elderly [40]. The National Osteoporosis Foundation (NOF) recommends 30 min of weight-bearing functional activities (e.g. brisk walking) for most days of the week[40] in combination with 1–2 sets of closed chain and open chain strengthening exercises of the trunk and hip girdle.
Either free weights or theraband can be used for resistance.
Postural re-education focuses on proper spinal alignment in sitting, standing, and lying. Flexibility exercises combined
with posture education may maximize proper posture.
Strength training with or without resistance, core stability exercises and dynamic and static balance exercises are employed to enhance strength and improve balance, thereby reducing the risk of falls. Scapular adduction exercises, wall slides, repeated sit-to-stand exercises are simple, safe and effective for older adults. Initial examination of scapular movement should be conducted prior to implementing scap- ular exercises. Manual facilitation techniques can be used to promote proper scapular patterns of movement during exer- cises. Examples of core strengthening exercises include pel- vic tilts, bridging, and cat and camel exercises. Sequencing of core stabilization exercises is necessary to ensure proper execution of exercises prior to progression. Static and dynamic balance exercises include single leg stance activi- ties and weight shifting exercises. Table 12.3 summarizes studies for exercise intervention for postmenopausal women with osteoporosis [34–39].
Rheumatoid Arthritis
Rheumatoid arthritis (RA) is a systemic, inflammatory disorder characterized by exacerbations and remissions that affects the joints in a symmetrical and polyarticular pattern [41].
The wrists, hands [metacarpophalangeal (MCPs) and proximal interphalangeal (PIPs)], feet, ankles, knees, and spine are com- monly involved. The predominant pathology in RA is synovial inflammation, which may lead to chronic synovitis and poten- tially joint destruction. RA is more common in the cervical spine. Systemic manifestations of RA may involve the cardio- vascular system, pulmonary system, the integument, and the nervous system. Rheumatoid arthritis significantly limits function and restricts independence.
Physical Examination Findings and Interventions
During history taking, patients commonly report joint pain and tenderness, fatigue, malaise, and during periods of flare, fever. Physical examination findings include: reduced aerobic capacity compared to healthy adults of similar age [42], adap- tive shortening of soft tissues, tendons, and joint capsules.
Joints may be hot, swollen and boggy and extra-articular edema may be present [43]. These symptoms reduce joint mobility and function. With progressive disease, cartilage loss leads may contribute to joint subluxation particularly of the hands and feet. Older adults with RA, particularly those who have a history of corticosteroid use are at higher risk of osteoporosis [42].
107 12 Physical Therapy Management of Select Rheumatic Conditions in Older Adults
Table 12.3 Exercise interventions with and without calcium supplements in post-menopausal women with osteoporosis Author (year)
Study
design Sample Intervention Outcomes
Iwamoto et al.
(2001) [35]
RCT 35 Osteoporotic postmenopausal women with mean lesser than 30%
below the young adult mean (mean age 64.9 years)
Three groups. Duration 2 years:
(1) Training: Brisk walking and gymnastic exercises 5×/week for 2 years with Ca and Vit D supplements
(2) Detraining: Brisk walking and gymnastic exercises 5×/week for 1 year with Ca and Vit D supple- ments for 2 years
(3) Control: No exercises. CA and Vit D supplements for 2 years
Significant increase in lumbar spine BMD in training group at year 1 (4.33%) and year 2 (4.29) as compared to controls
Significant increase in lumbar spine BMD in detraining group at 1 year (4.5%) compared to controls Difference in BMD between detraining
group and controls not maintained over year 2
Rhodes et al.
(2000) [36]
RCT 44 Independently community dwelling elderly females (mean age 68.8 years)
Two groups. Duration 1 year:
(1) Supervised progressive resisted exercises for 1 h, 3×/week (2) Continuation of daily activities
No significant changes observed in femoral neck, Ward’s triangle. Trochanteric or lumbar BMD in exercisers and controls.
Significant increase in specifically exercised muscle groups, quadriceps (19%), pectorals (29%) and biceps (20%) observed
Ebrahim et al.
(1997) [39]
RCT 165 Post-menopausal women with h/o upper arm fracture in past 2 years (considered at risk of future osteo- porotic fracture) (mean age 67.3 years)
Two groups. Duration 2 years:
(1) Brisk walking 3×/week for 40 min and education on general health and diet
(2) Education on general health and diet and simple upper limb exercises
Net 2% increase in femoral BMD decrease in rate of decline in brisk walkers. No significant difference in spine and femoral BMD in exercisers and placebo group. Brisk walkers had increased number of falls
Hartard et al.
(1996) [34]
NRCT 34 Postmenopausal women with over 30% bone loss, seen on lumbar spine and femoral neck X-rays (mean age 64.4 years)
Two groups. Duration 6 months:
(1) 1–2 sets of high intensity strength- ening exercises at 70% 1RM for large muscle groups of the body performed 2×/week
(2) No physical exercise
No significant difference in lumbar spine BMD in exercisers and control group.
However control group had 6.2% decline in lumbar BMD as opposed to 0.3%
increase in exercisers
Femoral neck BMD declined significantly in control group (0.07%) as compared to exercisers who had only 0.01% decline 44–76% increase in strength of exercisers Korpelainen
et al.
(2006) [37]
RCT 120 Elderly women with low BMD at the radius and hip (2SD below the reference value at both sites) (mean age 72 years)
Two groups. Duration 30 months:
(1) Supervised impact exercises including jumping and balance exercises for 60 min × 6 months, followed by 20 min daily HEP × 6 months
(2) No exercise and education
Significant decline of trochantric BMC from baseline in both groups. BMC in controls was significantly greater than exercisers.
Significant decline in femoral neck BMD in control group. Significant decline in radial BMD in both groups. Non- exercisers had significantly greater decline in distal radial BMD
MD. More fall-related fractures in control group
Yamazaki et al.
(2004) [38]
NRCT 50 Postmenopausal women with osteopenia/
osteoporosis (mean age 64.8 years)
Two groups. Duration 1 year:
(1) Brisk walking at predetermined speed with greater than 8,000 steps or 1 h; 4×/week. Dietary advice for calcium consumption of >800 mg (2) No exercises. Dietary advice for
calcium consumption of >800 mg
Lumbar BMD increased in exercise group (1.71%) and decreased in controls (−1.92%) however, no significant difference at 12 months
However significant percentage change in BMD exercisers at 12 months RCT randomized control trial, NRCT non-randomized control trial study, BMD bone mineral density, BMC bone mineral content
Subluxation of the MCPs and interphalangeal joints and ulnar deviation of the hands and wrists is common. Prolonged flexed positions of the hands and other joints may shorten soft tissue and contribute to contractures. Loss of plantar fat
pads and atrophy of the foot intrinsic muscles may lead to pain with ambulation and weightbearing. These symptoms coupled with subluxation of tendons, can produce hammer toes and metatarsal subluxation [44]. Excessive pronation of
the forefoot may result from overstretching of inflamed soft tissue and weaken foot intrinsic muscles, lengthening the medial arches.
Functional limitations and gait abnormalities arise from joint contractures, subsequent joint malalignment and mus- cle weakness. Muscle weakness can be attributed to myosi- tis, type I and type II muscle fiber atrophy [45], from inactivity, or from aging. If myositis is present, active resis- tive exercise should be avoided [46]. Muscle changes may be exaggerated with natural age-related changes (see Chap. 25). Table 12.1 provides a summary of clinical features and physical therapy intervention for RA [9].
A comprehensive physical therapy examination informs the intervention. Interventions are based on disease state (acute flare, subacute, or stable disease) as well as disease severity and the patient’s goals for intervention [47].
Intervention goals typically include: maximizing strength, flexibility, endurance, and mobility, and to promote indepen- dence while reducing the risk for further joint destruction and deformity. Physical therapists use an array of interven- tions to address patient goals including: exercise, orthoses, adaptive ADL equipment, ambulatory aids, modalities com- bined with patient education.
Patient education encompasses information on energy conservation techniques. Patients are encouraged to sleep 8–10 h per night and take frequent rests during the day, par- ticularly during a flare [47]. Information regarding proper joint positioning in neutral rather than flexed postures helps reduce joint deformity. Patients are taught to reduce physical activity levels during flares when their joints are red, hot, painful, and inflamed. Once these acute symptoms subside, patients can engage in aerobic and strengthening exercises. To best implement strengthening and progressive exercises, ther- apists should teach patients what to expect regarding discom- fort during or after exercise. For example, acute pain during exercise is bad and indicates a need to modify the exercise.
Mild muscle aching that resolves in less than two hours can be expected as activity levels increase [42]. One challenge of therapy is to help patients incorporate exercise into daily routines and identify their preferences for exercise regimens (e.g., social support, group vs. individual programs, etc.).
Social support for exercise enhances adherence [48]. A recent review of the literature indicates high quality evidence for the beneficial effects of patient education and joint protection in RA [49].
Patients in an acute flare may benefit from gentle daily active ROM exercises and isometric exercises to maintain strength and improve function, without placing stress on the soft tissues or additional shear forces on the joint [45, 50].
Caution should be taken, especially in older adults with RA, when prescribing sustained isometric exercises of large mus- cles as these exercises increase cardiovascular load [42]. During a flare, cold therapy is recommended to reduce inflammation
and relieve pain and passive stretching should be deferred until the inflammation subsides [42]. Heat should be avoided as it may exacerbate inflammation [50]. Performing ROM exercises early in the day when the joints are stiff may be difficult so patients should be encouraged to perform these during a warm shower or in the evening [9, 51].
Resting splints and dynamic splints for the hands and wrists can be used to maintain joint alignment and support inflamed structures. One study reported no differences with respect to pain, stiffness or grip strength with the use of dynamic splints [52] and suggests these splints may reduce dexterity. However, Stern et al. [53] found no difference in hand dexterity in a study evaluating three types of dynamic splints. Clinically splints are often prescribed. Also, extra depth shoes, shoes which have an additional 1/4 to 3/8 in. of volume, and shoes made of heat moldable material, can be worn to accommodate forefoot changes [54]. Extra depth shoes combined with a semi-rigid orthotic are more effective in reducing pain that extra depth shoes alone [55].
When the inflammation subsides, heat or cold can be used to relieve pain. Local heat prior to exercise reduces join stiffness and facilitates movement. While the evidence for physical modalities such as thermotherapy, ultrasound, paraf- fin, TENS, and low-level laser therapy is limited, there is some evidence to support their effectiveness in reducing pain and increasing extensibility of soft tissue [49, 56]. At this time, ROM exercises performed each day can increase and active resistive exercises should be incorporated. Resistive exercises of moderate intensity demonstrate improvements in strength and function without exacerbating joint damage [49].
Non- or low-impact aerobic exercises such as walking, cycling, or aquatic exercises are particularly important to incorporate as many patients suffer from deconditioning either as a direct result of the disease, from medication side effects, from natural changes, or a combination of these factors [57].
Aquatic exercise regimes use the water’s buoyancy to reduce load and its compressive forces to diminish joint swelling and pain [58]. The ideal water temperature to reduce pain, muscle spasm, and joint stiffness is 37°–40°C [46]. The outcomes of moderate to high intensity exercise is less well-studied and are therefore, less frequently prescribed. One recent trial [59]
suggested some benefits for patients but among those who began the trial with changes in the hips and knees there was some progression of disease and recommend caution in pre- scribing exercise to patients who already have significant joint damage, particularly in the large weight bearing joints [60].
Assistive devices may be prescribed to help patients man- age activities of daily living and ambulation. Often platform attachments can reduce and distribute weight-bearing forces over the forearm reducing discomfort. Cone type handgrips and those with wider, flatter hand grips can help improve handling, are more comfortable, and maintain better hand positioning.
109 12 Physical Therapy Management of Select Rheumatic Conditions in Older Adults