Geriatric Physical Therapy 3rd edition

492 CHAPTER 26  Patient Management in Postacute Inpatient Settings psychotropic medications, and have multiple comorbid responses to positional change, and functional tests of conditions.59 These characteristics can help the therapist endurance. consider the contribution of orthostasis to falls and fall risk. Tests and Measures Systems Review Strength.  Muscle strength is a predictor of function in the older adult, and because most LTC residents have The senses of hearing and vision are expected to decline difficulty with ADLs, it can be safely presumed that most as a normal part of aging, and losses are common find- LTC residents have severe strength deficits.70 For exam- ings in most nursing home residents. Hearing loss is the ple, to stand from a normal chair without the use of arms most prevalent of all sensory losses, affecting an esti- requires leg strength of nearly half of the body weight.71 mated 30% to 46% of individuals over age 65 and 90% If a resident cannot walk without weight bearing on his of individuals over age 80.64 Vision losses from cataract, or her arms secondary to leg weakness, it can be pre- glaucoma, diabetic retinopathy, and macular degenera- sumed the resident has lost 75% of his or her reserve tion have all been shown to decrease quality of life.65 strength.72 Therefore strength assessment is vital to the Population-based studies have reported the prevalence physical therapy examination. However, the traditional of functional visual impairment to be 16% among indi- manual muscle testing (MMT) has inherent limitations, viduals age 80 years and older and 39% for those older especially in the LTC setting. MMT is not a quantitative than age 90 years.65,66 In a sample of 198 nursing home assessment method for strength and has been shown to residents, researchers asked residents whether they had lack accuracy when used as a screening test.73 Bohannon difficulty hearing in a group, while watching television, et al have shown that MMT has severe ceiling effects for or while talking on the telephone. This three-question grades higher than 5/5 with a range from 85.4 to 650.0 method was significantly more effective than the use Newtons.74 MMT may not be easily performed in some of a single hearing loss question in predicting which patients with cognitive impairments, ROM, or mobility residents had hearing loss as measured by audiometric limitations. Therefore, MMT will not correlate with assessment.67 functional tasks on certain patients. Therapists may over- or underrate strength by observing function. For exam- Residents often wear corrective lenses. However, ap- ple, Bohannon found that if a patient is able to stand up proximately 25% of residents in LTC settings who from a chair without the use of his or her arms, it is safe wear corrective lenses still have moderate vision im- to assume that strength on the quadriceps is at least pairment, that is, vision less than 20/70.68 Information 41/5.75 The therapist may determine the resident has about residents’ hearing and vision is important when “normal” strength and not incorporate appropriate the therapist is determining the best way to teach and strength training. Besides strength deficits, the cue a patient and should be noted in the initial evalua- resident may also exhibit poor balance or be afraid of tion and the plan of care. Specific visual pathologies falling, affecting task performance. The resident may such as cataracts, macular degeneration, or glaucoma have difficulty understanding instructions or simply have different presentations and visual effects that can not want to perform the task, issues insensitive to MMT. impede physical therapy interventions. Awareness of For these reasons, we advocate a functional testing visual pathology presentations will help the therapist perspective. provide the most effective education and cueing. Thera- Functional Assessment.  F​ unctional assessment plays a pists need to be cautious to differentiate poor cognition vital role in demonstrating and documenting the outcomes from poor hearing, and lack of interest from poor of rehabilitation and should be an assumed standard of vision. practice for all geriatric practitioners.75,76 Many assessment tools that measure and analyze gait and balance require Control of bowel and bladder functioning also should some level of resident comprehension and willingness to be noted. Approximately 49% of residents in LTC are participate. Considering the great number of residents suf- incontinent of urine.69 Incontinence is reported to be fering from dementia and depression in LTC settings, the highly associated with impairment in ADL, the presence use of some of the standard tests may be challenging for the of dementia, restraint use, the use of bedrails, and the therapist.77-79 We have listed some functional tools we find use of antianxiety/hypnotic medications.69 For many most valuable for residents of LTC settings, including func- residents, incontinence or bowel/bladder accidents may tional markers for different abilities (Table 26-2).80 likely be due to impairments in ADL. The data obtained from the tests and measures are Residents may have chronic conditions affecting used to make a clinical judgment (evaluation) and to the heart and lungs, and many have mobility con- establish a diagnosis and prognosis. The physical thera- straints, which may affect skin condition. Therefore, pist has great autonomy in the LTC setting and will de- cardiac, pulmonary, and integumentary systems require termine the dosage of interventions and when to special attention. Aerobic capacity and endurance tests include vital signs at rest and after activity, autonomic

CHAPTER 26  Patient Management in Postacute Inpatient Settings 493 TA B L E 2 6 - 2 Functional Markers for Older Adults Functional Marker Physically Frail Physically Independent Dependent .30 s Timed Up and Go 10 to 20 s .20 s ,0.35 m/s (walker) Gait speed 0.8 to 1.5 m/s 0.35 to 0.8 m/s ,800 feet 6-Minute Walk 1800 to 1500 feet (walker) Unable Walk 1 mile 18 to 33 min 1500 to 800 feet Unable Floor transfer 10 to 30 s (with or Unable .30 s with assistance ,30 Berg Balance Scale without assistance) (56 total) .48 30 to 48 .30 s 0 10 stairs (up or down) 5 to 15 s 15 to 30s Unable 30-s chair rise .15 ,8 Timed 5-repetition chair 10 to 15 s .15 s ,4 rise 12 to 0 0 to 2 4 ,8 Reach to toe while sitting Unable 10 to 2 4 2 4 to 2 8 Unable (sit and reach test)* 5 to 10 s ,5 s Back scratch test* 10 to 30 s ,10 s Tandem stance Single-leg stance *Flexibility norms differ for females and males, with females having higher flexibility norms than males. (Avers and VanBeveren, Course notes, SUNY Upstate Medical University, October 2009.) discharge from skilled therapy. It is imperative to con- individuals become more confident of their abilities.83 stantly reassess the individual to determine when to refer Martin Ginis et al compared a weight training alone them to a maintenance (restorative nursing) program. treatment (WT) to an innovative WT plus educational treatment (WT1ED) to investigate strength gains, ADL INTERVENTIONS self-efficacy, and performance.81 The WT1ED partici- pants increased self-efficacy for performing ADLs beyond Exercise the effects attributable to strength training alone. The findings suggest that ADL performance–related strength Probably the most crucial type of training in LTC is education can help older adults understand the relation- active participation in meaningful activities. Residents ship between exercise program strength gains and the may not understand why they are asked to perform cer- application of those gains to ADL performance. tain exercises and may not see the potential benefit of exercise performance.81 Older adults must see the con- Exercises that are meaningful to the older adult not nection between their resistance training improvements only improve exercise adherence but also provide gains and the performance of ADLs. in functional capacities. It has been documented that older adults can adapt physiologically to exercise train- One of the strongest motivators affecting exercise ad- ing similarly to younger adults, if specificity is incorpo- herence in older adults is self-efficacy, the confidence in rated.87 de Vreede et al performed a randomized con- one’s ability to carry out a planned behavior.82,83 When trolled trial to determine whether a functional-task an exercise directly improves ADLs, it may then generate exercise program and a resistance exercise program have exercise adherence. A second motivator is outcome ex- different effects on the ability to perform daily tasks.86 It pectation, which is the belief that specific consequences was found that functional task–specific exercises are will result from specific personal actions.82,84 Older adults more effective than resistance exercises at improving who adhered to exercise are characterized by an inner functional task performance in healthy older adult motivation to exercise, a belief that they were able to women and may have an important role in helping them exercise safely (self-efficacy), a recognition of the benefits maintain an independent lifestyle. Manini et al had of exercise (outcome expectation), and the ability to set similar results in a study to determine the efficacy of specific activity-related goals.82 Self-efficacy has been 10 weeks of resistance (RT), functional (FT), or func- shown to be a predictor of stair-climbing ability, balance, tional plus resistance (FRT) training in 32 older adults and general functional decline in older adults.85 In addi- (75.8  6.7 years).87 Participants completed 20 training tion, it is also a strong predictor of exercise participation, sessions within approximately 10 weeks. The authors especially in women.86 Efficacy scores increase as older found that those who performed only FT improved in

494 CHAPTER 26  Patient Management in Postacute Inpatient Settings both components of functional ability (task modification measures included strength (1 RM), gait speed, stair- and timed performance), but did not have consistent climbing power, nutritional intake, body composition, adaptations in muscle strength. Those individuals who and physical activity. The strengthening intervention performed only RT increased muscle strength, but only significantly improved muscle strength and increased reduced task modification and not timed performance. quadriceps cross-sectional area, habitual gait speed, stair- Individuals who performed 1 day of each training type climbing power, and overall level of physical activity. The had less dramatic changes in muscle strength and func- nutritional supplement did not provide additional benefit tional ability than the other two groups but had consis- to the changes seen with exercise alone. The design and tent improvements in both components of functional number of subjects in this study provide the most con- ability and muscle strength.87 These data suggest an im- vincing evidence that high-intensity strengthening exer- portant role of task specificity when designing exercise cises in frail, institutionalized older adults is safe and programs to improve physical function in lower-func- effective in improving both impairments and functional tioning older adults. limitations. Age is not an appropriate characteristic to determine Evans studied a population of 100 frail, institutional- application of specific interventions. Too often, in the ized older adults (age range 87 to 96 years) randomly authors’ opinion, physical therapy practice in LTC re- assigned to high-intensity strength training for the quad- flects low expectations by the therapist and often by the riceps muscle.94 Initial strength levels were extremely resident. Frequently, LTC residents are viewed as too low in these subjects, with a mean 1 RM of 8 kg for the frail or too cognitively impaired to benefit from best quadriceps. The absolute amount of weight lifted by the practices such as high-intensity strengthening, motor subjects during the training increased from 8 to 21 kg. learning principles, electromodalities, and task-specific The average increase in strength after 8 weeks of resis- training. Unfortunately, there is a tendency to be too tance training was 174%  31%. The substantial in- conservative when prescribing exercises to older patients creases in muscle size and strength were accompanied by even though studies have long shown that older adults clinically significant improvements in tandem gait speed can gain as much benefit from intense strength training and index of functional mobility. Repeat 1 RM testing in as younger individuals.88 Prescribing exercise that is in- seven of the subjects after 4 weeks of no training showed tense enough to provoke a strength-training effect of at that quadriceps strength had declined 32%. Additional least 60% of a 1 repetition maximum (RM; or 15 RM) research has shown that strength training, when done at for 1 set will achieve functional gains and can be moti- appropriate levels of intensity based on the 1 RM, may vating as well.89 minimize or even reverse the syndrome of physical frailty prevalent among very old individuals.94 Based on evi- Older adults themselves may have misconceptions dence, we advocate and strongly encourage the prescrip- and lack of knowledge about strength training and tion of moderate to vigorous exercises centered on a therefore be resistant to an intense exercise regimen. In program established according to the patient’s 1 RM. another study by Manini et al, 129 older adults (77.5  However, the frail older adult can still make gains that 8.6 years) responded to questions about their opinions, may be more related to improved motor learning and experiences, and knowledge of strength training recom- movement efficiency than actual strength gains with a mendations.90 Forty-eight percent of older adults be- low- to moderate-intensity program. lieved that strength training would not increase muscle mass, 45% said that increasing weight is not more im- The intensity principle should be applied to aerobic portant than number of repetitions for building strength, conditioning as well, using a percentage of heart rate and 37% responded that walking is more effective than reserve. Foster et al compared the effects of moderate- lifting weights at building strength. Clearly, physical and low-intensity exercise in women with a mean age of therapists have an important role educating older adults 78.4 years residing in retirement homes.95 The women on the benefits and appropriateness of strength training. were randomly assigned to either an intervention group that walked 3 times a week at a heart rate that corre- It is well known that the frail older adult can achieve sponded to 60% of their heart rate reserve or an inter- improvements in strength, balance, and endurance with vention group that walked 3 times a week at a heart rate training at any age.91,92 A large controlled trial of a that corresponded to 40% of their heart rate reserve. strengthening regimen for frail older adults was con- After 10 weeks of training, both groups showed improve- ducted by Fiatarone et al.93 In this study, 100 nursing ments in maximal oxygen consumption, but there was no home residents (mean age 5 87 years) were randomly difference between groups. Similarly, MacRae et al per- assigned to one of four groups: high-intensity strengthen- formed a randomized controlled trial investigating the ing, nutritional supplementation, strengthening and nu- effects of a walking program on walk endurance capac- tritional supplements, or a placebo exercise/nutrition ity, physical activity level, mobility, and quality of life in control group. Strengthening was targeted to the hip and nursing home residents.96 The 22-week intervention re- knee extensors, at an intensity of 80% of the subjects’ quired that the residents in the intervention group walk 1 RM. The residents performed three sets of eight repeti- at their habitual pace for a maximum of 30 minutes per tions three times per week for 10 weeks. The outcome

CHAPTER 26  Patient Management in Postacute Inpatient Settings 495 day. The results showed that the daily walking routine adult population has been related to an increased risk for improved residents’ walking endurance but did not falls, which, in turn, often leads to a loss of independent improve the other outcome measures.96 The results of living and to institutionalization.107,108 these studies suggest that low-intensity exercise (of suffi- cient duration) may be enough of a stimulus to produce UNIQUE CHALLENGES IN THE LTC some cardiovascular changes in these individuals, but SETTING functional change appears to require directed, intense, preferably task-specific training of sufficient intensity. Fall Risk Reduction Gait Training Falls prevention is an important component of caring for the aging adult. Although what constitutes successful fall Older adults often recognize changes in their gait pat- intervention in LTC has not been determined, some pro- terns and speed and feel that they cannot walk “the way gram characteristics are promising. For example, Shimada they used to.” Gait speed has been shown to be a predic- studied a group of 32 LTC facility residents and outpa- tor of functional decline, nursing home placement, and tients aged 66 to 98 years who were randomly assigned mortality.97-100 Oberg et al and also Bohannon reported to a usual exercise group or to a treadmill exercise that habitual gait speed may decrease by 9% to 11% group.109 Perturbed gait exercise on a treadmill continued and fast gait speed may decrease by 8% to 18% between for 6 months. The number of falls and the time to first fall the fourth and eighth decades.101,102 When gait speed during a 6-month period, balance and gait functions, and slows below 1.0 to 1.2 m/s, older adults are reported to reaction time were evaluated before and after interven- have more difficulty crossing the street safely before the tion. The number of falls on the treadmill exercise group traffic light changes.103,104 Potter et al reported that older was 21% lower than that in the usual exercise group. Gait adults with a gait speed of ,0.25 m/s were more likely training with unexpected perturbation seems to have a to be dependent in one or more ADLs.105 Gait speeds of beneficial impact on physical function in disabled older 0.5 m/s or less are not uncommon in an LTC setting and individuals. Ray et al evaluated a falls prevention inter- indicate the severe loss of strength associated with frailty vention in nursing home residents who were at a high risk and sedentary behavior. Lower-extremity therapeutic of falling.110 The 267 control subjects resided in different exercise has been reported to improve muscle force- nursing homes than the 232 residents who received the generating capacity and flexibility, which are needed for intervention. An interdisciplinary falls consultation team gait.106 Thus, improving lower-extremity muscle force conducted the intervention and attempted to decrease and flexibility, along with aerobic fitness and upright unsafe practices in the following four domains: environ- balance training, are expected to result in an improve- mental and personal safety, wheelchairs, psychotropic ment in gait speed. We advocate the measurement of gait drugs, and transferring and ambulation. Residents’ rooms speed over a 4-m walkway for every resident. Usual and were assessed for environmental hazards, wheelchairs fast gait speed should be measured with an expectation were assessed and modified as needed, psychotropic drug of 0.33 m/s difference between usual and fast gait speed, use was evaluated in ambulatory residents, safety in trans- which may indicate a measurement of reserve. Many fers and gait was evaluated, and inservices were given to clinicians may find that residents only have one walking all nursing home staff regarding causes and consequences speed and thus an intervention could be to walk for of falls and for recognizing environmental hazards. The short distances as fast but as safely as possible. outcome measures were the number of recurrent fallers and the number of injurious falls. An average of 15 rec- Gait training in the institutionalized older adult ommendations were made per patient. The intervention should be no different than in other settings where the group showed 19% fewer recurrent fallers and 31% therapist analyzes stance and swing phases, observes fewer injurious falls. The program was more effective step length and symmetry, notes compensations, and among the residents who had three or more falls the prior generates hypotheses as to the causes of the limitations year and when compliance with the recommendations (impairments). Therapists should realize that causes of was achieved. These results suggest that high rates of falls gait dysfunction in the institutionalized older adult may can be lowered through interdisciplinary approaches in be of a chronic nature and that some of the impairments LTC settings. Physical therapists should be active mem- may not be reversible. However, any impairment noted bers of the falls reduction teams, present in most facilities. should not be assumed to be attributable to “geriatric gait” but rather an indication of an underlying gait im- Restraint Reduction pairment that may be corrected or modified. Although the impairment may not be reversible, the functional The Omnibus Reconciliation Act of 1987 specified that limitations may improve if treatment is directed at bal- residents have the right to be free from restraints, and ance, speed, and compensatory strategies. Improving therefore, restraints are used only when all other alterna- gait to decrease the risk of falls is of extreme importance tives to prevent injuries have failed.111 Most institutions in most LTC settings. Slowed gait speed in the older

496 CHAPTER 26  Patient Management in Postacute Inpatient Settings have programs in place to reduce the use of restraints. In an intervention for decreasing knee flexion contractures the LTC setting, physical therapists are often consul- in institutionalized older adults by comparing high-load tants, and assume leadership roles in finding alternatives brief stretch to low-load prolonged stretch.116 The pro- for the use of restraints. Some of the alternatives for the tocol suggested by Light et al consisted of a 1-hour dura- use of restraints include engaging residents in physical tion stretch, twice a day for 4 weeks. The intensity of the activities, increasing participation in leisure activities, stretch was such that the slack was taken up in the and increased supervision from staff, which can be dif- muscle. The stretch was maintained by a traction unit ficult and sometimes overwhelming. Commonly used that hung off a plinth. High-load brief stretch consisted alternatives to restraints are low beds, mattresses on the of a proprioceptive neuromuscular facilitation technique floor to prevent injury in case of a fall out of bed, wheel- to hold the muscle at its end range for 1 minute, fol- chair or bed alarms, and beds with no railings. Some lowed by a 15-second rest, and then the process was re- facilities have adopted the use of hip protectors to reduce peated three times. Low-load prolonged stretch tech- the likelihood of fracture if a fall were to occur; however, niques were found to be more effective than high-load the evidence on hip protectors is equivocal.112 brief stretch in reducing knee flexion contractures. There are many reasons why residents prefer having a Mollinger and Steffen measured knee flexion contrac- bed rail, including the sense of security it seems to offer tures in nursing home residents for 10 months.117 They and the bed rail’s ability to enable rolling. Bed rails reported that 75% of their sample of 112 residents had are common in LTC but are considered a restraint if unilateral knee flexion contractures of greater than the resident is unable to lower the rail independently. 5 degrees. The presence of knee flexion contractures was And while the rail may seem to prevent injury and falls, associated with resistance to passive motion, cognitive the opposite is actually the case. Between January 1, impairment, impaired ambulation, and complaints of 1985, and January 1, 2009, the Food and Drug Admin- knee pain. Their results suggested that residents whose istration (FDA) received notice of 803 incidents of knee flexion contractures approached 20 degrees may patients caught, trapped, entangled, or strangled in hos- also develop subsequent ambulation impairment; there- pital beds.113 The reports included 480 deaths, 138 non- fore, skilled intervention may be indicated in these fatal injuries, and 185 cases where staff needed to inter- patients. vene to prevent injuries. Physical therapists should consider these facts when assessing functional indepen- When contracture is already present, the therapist dence in the LTC setting. should not only take the accurate ROM measurement but also assess the nature of the contracture by differen- Contracture Management and Risk tiating fixed contractures (with no give in ROM by pas- Reduction sive stretch) from a nonfixed restriction (with a gain in ROM with stretch) and rigidity from spasticity (neuro- Contractures are a common consequence of prolonged logic) in order to establish the best intervention. physical immobility among nursing home residents and further reduce mobility and increase the risk of other ill Pressure Ulcer Management and Risk effects of decreased mobility, such as pressure ulcers.114 Reduction Almost two thirds of the LTC residents in a study per- formed by Wagner et al had at least one contracture, Physical therapists are often the first ones to observe red- with the most common locations being the shoulder and ness or tender points in nursing home residents, fre- knee.115 ROM is often limited in nursing home residents quently in bed-bound, nonverbal patients. Careful skin and needs to be assessed carefully, especially in the bed- inspection should be part of the physical therapist’s as- bound residents.69,114,115 Accurate measurement is the sessment. Sharing the findings with nursing staff, and best way to detect contractures and provides the thera- providing alternatives for position is a primary task of pist objective numbers to refer back to in case there is a the physical therapist in this scenario. reported decline and a new evaluation needs to be per- formed. There have been only a few studies that have The prevalence of pressure ulcers varies from 2% to evaluated interventions for contractures. Fox et al stud- 24% among long-term patients.118 The incidence and ied the effectiveness of a bed positioning program for the prevalence is more than 60% in high-risk patients, in- treatment of patients with knee flexion contractures.114 cluding older individuals with femoral fractures.118 Risk The bed positioning program consisted of stretching a factors for pressure ulcers include immobility or re- patient’s knee into extension and then securing and stricted mobility, loss of bowel and bladder control, maintaining the position for a period of 40 minutes four poor nutrition, and impaired mental awareness.119,120 times per week. There was no improvement in partici- Preventive interventions, such as frequent repositioning, pant’s ROM. The result of the study does not support tissue load management, and ensuring adequate nutri- the use of bed positioning programs for treating patients tion, has been shown to help prevent pressure ulcer for- with knee flexion contractures. Light et al investigated mation among patients at risk.121 The most practical method for reducing pressure is to turn and position the patient frequently. In a study

CHAPTER 26  Patient Management in Postacute Inpatient Settings 497 demonstrating the effectiveness of repositioning, higher refer patients to these restorative nursing programs upon nursing staff ratios may have resulted in demonstrating discharge from skilled physical therapy as a type of “step- increased effectiveness of pressure sore prevention.122 down” program for the residents or if the therapist deter- Because of the limitations and cost of turning the patient mined that the resident does not require the skills of a frequently, a number of devices have been developed for physical therapist. Restorative programs may include turn- preventing pressure injury. The only devices that consis- ing and positioning programs, wheelchair mobility and tently relieve pressure on the trochanter, ischium, and endurance programs, ambulation, ADL programs, active sacrum are low-air-loss and air-fluidized beds, and their ROM programs, and restorative dining programs, among long-term effectiveness is controversial.123 Malnutrition others. Programs that encourage walking as part of the has been linked to an increase in the risk of skin ulcers resident’s daily routine (e.g., walking to the dining room) and to delayed healing.124 During periodic screenings, have been reported to increase overall ambulatory endur- therapists should speak with dieticians and certified ance, decrease fall rates, decrease incidences of inconti- nursing assistants involved in feeding to identify resi- nence, and inhibit functional decline.96,125-128 dents who are malnourished or at high risk for malnour- ishment, thereby attempting to indirectly reduce the risk Trained restorative aides generally carry out restor- of pressure sores. Some useful questions that can be ative nursing programs. These programs can be quite asked are the following: effective if both nursing and rehabilitation staff are com- mitted to their success. Programmatic features that • Has there been any weight loss? should be present in a restorative nursing program • If the resident wears dentures, do they fit appropri- include: ately and are they being used? • method of screening to assess functional abilities or • Does the resident eat independently or with assis- to classify patients according to program require- ments or guidelines, tance? • If the resident requires assistance eating, has there • means of reassessment to determine whether resi- dents continue to need the services, been a recent change in the level of assistance required? • documentation/communication system to convey in- formation about patients to all staff involved in the In summary, the list below highlights the role of the program on an ongoing basis and to ensure account- physical therapist in managing and preventing pressure ability, and sores in the institutionalized older adult: • method of objectively evaluating the effectiveness of • Educate nursing staff whenever needed on proper the program and determining whether program goals transfers and lifting techniques to avoid skin injury have been met.127 from friction/shear. Communication between the therapist referring the • Recommend a turning and repositioning schedule for resident to a restorative program and the clinician run- residents that are at risk. ning it is fundamental. Some facilities keep a log with descriptors of their residents’ participation and restor- • Leave residents with pillows or other devices to keep ative goals that have or have not been achieved. This bony prominences from direct contact with each may be a quick and effective way to supervise a resi- other. dent’s performance. A good time to interview the staff member responsible for the restorative program is dur- • Teach residents to perform small and regular weight ing a periodic screen. The physical therapist should ask shifts. about residents’ participation in the program and whether they are achieving the desired results. It is not • Recommend proper pressure-reducing devices for the uncommon for residents to improve slowly, over time, wheelchair and bed and be familiar with current while on a restorative program. Do not confuse this with products available. skilled therapy, where significant functional gains are expected in a reasonable time frame.54 Any major • Keep residents as active as possible; promote mobili- changes in performance, for better or worse, should war- zation by referring to restorative programs and rant a complete physical therapy evaluation. encouraging participation in social events. DEALING WITH DEMENTIA RESTORATIVE PROGRAMS AND DEPRESSION When it is determined by the therapist’s evaluation that a Dementia is the most common reason for placement of resident is not appropriate for skilled services, physical the older adult in nursing facilities.76 Depression affects therapists also have an active role in teaching nursing staff up to 25% of patients in a nursing home setting and is the most appropriate transfer techniques, aids for proper associated with significant morbidity, mortality, disability, positioning, donning and doffing braces and splints, guard- ing techniques during ambulation, and development of a restorative nursing program to maintain current status and prevent risk of functional decline. Physical therapists often

498 CHAPTER 26  Patient Management in Postacute Inpatient Settings and suffering for patients and their families.74,128,129 The these results, physical therapists need to be engaged in presence of dementia or depression may pose challenges the discussion and treatment of patients with depression for the physical therapist that require creativity in engag- in LTC and other settings. ing the resident. The resident who is depressed may be more likely to participate in activities that were enjoyed Physical therapists are introducing LTC residents prior to the onset of depression. For example, if the resi- to virtual technology applications such as the Nintendo dent enjoyed dancing, it could be incorporated into treat- Wii. Anecdotally, there appear to be increases in ment by having the resident move according to the music the treatment program adherence, some preliminarily to improve balance, or move according to the beat during positive outcomes, and increased patient engagement in gait training. Balls and competitions could be used for the clinic.132 The Nintendo Wii is a computer gaming residents who enjoy sports. Consideration of how to build console that offers simulated sports games, fitness, and self-efficacy as described earlier can be included. Residents other activities. The uniqueness of the console is that the who are cognitively impaired may not understand exercis- controller is wireless and can detect acceleration and ing for the sake of exercising, or in severe cases, not even orientation in three dimensions. Although more defini- understand the instructions given. Therapists often strug- tive research is needed, improvements in balance have gle with this challenge, and unfortunately may exclude the been demonstrated in nursing home residents.132 A num- resident from skilled therapy claiming that the resident is ber of the sports games can be played in a sitting posi- unable to participate. However, therapists should attempt tion, and opens many possibilities for the wheelchair- to include the confused resident in activities that are bound population. Cognitively impaired patients may meaningful, or make sense. For example, a resident who also participate.132 The key challenge is for the therapist was a housewife for her whole life may be able to fold to choose the appropriate program. Boxing, for exam- towels and sheets. The therapist can use that activity to ple, is considered a good starting place as all that a work on balance, standing tolerance, or upper extremity participant needs to do is to swing alternate arms motion. A resident who refuses to stand up from a chair forward repetitively. There are also potential social when asked to may automatically stand up to answer the benefits from such games. Residents may gather around phone or the door and may agree to “go for a walk” to to see other residents in action. For residents, simulation look for something or someone. technology can stimulate the fun of attending or partici- pating in a sport event. Although beneficial to patients Often, persons with Mini Mental State Examination with dementia or depression, these types of simulators (MMSE) scores lower than 25 are excluded from physi- have a much broader applicability in the modern cal rehabilitation programs.79 However, evidence sug- clinic. gests that cognitively impaired older adults who partici- pate in exercise rehabilitation programs have similar FUTURE TRENDS IN POSTACUTE CARE strength and endurance training outcomes as age- and gender-matched cognitively intact older participants.74 Health care delivery and systems in the United States are These findings are consistent with those of Littbrand et changing rapidly. The CMS is interested in developing a al.130 The result of Littbrand et al’s study suggests that a new assessment tool.133 The tool is intended to replace high-intensity functional weight-bearing exercise pro- similar items on the existing Medicare assessment forms, gram is applicable for use, regardless of cognitive func- including the Outcome and Assessment Information Set, tion, among older people who are dependent in ADLs, MDS, and IRF-PAI tools. living in residential care facilities, and have an MMSE score of 10 or higher. Goldstein et al studied 58 patients Any initiatives from states and the federal government with hip fracture, 35 with and 23 without cognitive im- to ensure the solvency of Medicare and Medicaid pairment to compare outcomes (physical function and programs are likely to affect postacute care settings in discharge destination) and to identify cognitive skills great measure. In coming years, there may be massive related to functional gains.131 They found that patients changes in health care payment methodology, systems of with hip fractures and cognitive impairments can achieve delivery, and continuity of care. Postacute care settings, positive outcomes as defined by functional gain (as de- including LTC, will see widespread implementation of termined by the FIM) and discharge destination. Clearly, electronic documentation and medical record keeping. cognitively impaired individuals should not be excluded The American Recovery and Reinvestment Act of 2009 from rehabilitation programs. alone dedicated some $19 billion toward assisting health care entities and providers with implementation of elec- Blumenthal et al assessed whether patients receiving tronic medical records.134 aerobic training achieved reduction in depression com- pared to standard antidepressant medication (sertraline It is clear that our current system will need to change HCl) and a greater reduction in depression compared to to keep up with the large numbers of aging baby boom- placebo controls.129 Their findings indicate that the effi- ers who will create the biggest demand on the Medicare cacy of exercise in patients seems generally comparable system the program has experienced since its inception. with patients receiving antidepressant medication and Physical therapists will continue to have an important both tend to be better than the placebo. Clearly, given role in the delivery of care in postacute care settings. Knowledge of evidence-based interventions, which are

CHAPTER 26  Patient Management in Postacute Inpatient Settings 499 both clinically effective and fiscally efficient, will be es- REFERENCES pecially important. Health promotion and wellness ef- forts should become standard practice for geriatric To enhance this text and add value for the reader, all physical therapists as our society shifts toward a more references are included on the companion Evolve site preventive model of health care delivery. The postacute that accompanies this text book. The reader can view the care environments, especially LTC, offer many opportu- reference source and access it online whenever possible. nities for physical therapists to make substantive contri- There are a total of 134 cited references and other gen- butions to changes in how the aging adult regains func- eral references for this chapter. tion and is able to have a meaningful, productive quality of life.

27C H A P T E R Hospice and End of Life Richard Briggs, MA, PT, Karen Mueller, PT, PhD THE CONCEPT OF A “GOOD DEATH” can be given similar options for the ways in which they affect their end of life. One of the most important Health care outcomes, regardless of one’s discipline, are contributions of hospice and palliative care is to assist generally focused on the enhancement of patient quality patients in making and carrying out these choices. of life. For each person, quality of life is a subjective, broad, and multifaceted construct, which includes all Physical therapists have an important role in support- elements that provide life satisfaction. Physical thera- ing a good death through a host of interventions to pists have a critical role in optimizing quality of life reduce pain, optimize the patient’s remaining function, through the application of skills related to the evaluation and enhance the quality of life for whatever time is left. and treatment of conditions affecting movement and In end-of-life care, physical therapy outcomes may not function from the moment of birth until the moment of be solely functional but can include improved sleep qual- death. ity, decreased physiological and psychological stress, improved respiratory function, and a decreased need for Nevertheless, because the typical expectation of phys- analgesic medication. More importantly, skilled physical ical therapy intervention is related to the attainment of therapy intervention can help the patient and family to improved function, the benefits of our services to those maintain safe, energy-efficient mobility in the presence facing end of life are often not considered. To that end, of declining systemic function, a process that can best be patients in a hospice setting may be told that “nothing described as “rehabilitation in reverse.” more can be done” by health professionals who are unaware of the value of physical therapy in maintaining A primary goal of this chapter is to examine the cur- safe and comfortable function in the presence of physical rent structure and process of hospice and palliative care, decline. Unfortunately, such lack of awareness may a growing health setting for all Americans, particularly prevent the optimization of quality of life in persons those in their later years. In addition, the roles, benefits, for whom death may be imminent yet still potent with and outcomes of physical therapy intervention in the opportunities for rich interactions. realms of hospice and end-of-life care will be explored. Most importantly, the information presented here should It does not have to be this way. The indignities of a enable the reader to advocate for the ongoing involve- lonely, painful, and helpless death are among the great- ment of physical therapists in this important area of est fears of Americans.1 Fortunately, in the past few care. Accordingly, because hospice and palliative care is decades, these fears have forced a reexamination of end- a newer area of physical therapist practice, rich opportu- of-life care, resulting in the development of the compas- nities exist for engagement in outcome studies to support sionate, patient-centered approach that defines hospice the value of these services. Finally, we should remember and palliative care. that participation in hospice and palliative care is an elegant reflection of the American Physical Therapy Central to the hospice approach is the construct of a Association’s 2020 Vision Statement, which directs us to “good death,” the inevitable outcome to which all effec- “maintain active responsibility for the growth of the tive end-of-life care is directed. This construct is the physical therapy profession and the health of the people obvious antithesis of our worst fears. Simply put, a good it serves.”2 Given that the overall outcome of interven- death is one where the dying person is free of discom- tions in hospice and palliative care relates to a death fort, in the presence of those they love and in the envi- with dignity, it is important to first understand the ronment of their choosing. physiological elements of the dying process. This knowl- edge is critical in providing compassionate support to This patient-centered approach is certainly not a for- patients and families as they navigate the poignant expe- eign concept in other areas of health care. For example, rience of this natural process. just as expectant mothers can orchestrate the manner in which their labor and delivery proceed, dying patients 500 Copyright © 2012, 2000, 1993 by Mosby, Inc., an affiliate of Elsevier Inc.

CHAPTER 27  Hospice and End of Life 501 THE PHYSIOLOGICAL PROCESS OF DYING or even hours before death. In one Swiss study of 56 older adult patients dying from cancer and other It has been stated that “we die of old age because we conditions, 44 (79%) received respiratory interventions have been worn and torn and programmed to cave in. from physical therapists (including side-to-side position- The very old do not succumb to disease, they implode ing for lateral chest excursion, chest mobilization, and their way to eternity.”3 As this quote suggests, advances guided breathing) up until their last 24 hours.6 The fol- in medicine have prolonged our lives so that the typical lowing section includes a description of common physi- American death is most likely to occur in the old and ological changes that accompany the death process, but very old from a chronic condition involving a period of it is important to note these will vary among persons. physiological decline. Accordingly, the Centers for Dis- ease Control and Prevention reported that of the The Dying Process 2,448,017 U.S. deaths that occurred in 2005, the four leading causes were heart disease (27%), cancer (23%), Physiological Changes Associated with Death.  The stroke (6%), and chronic lower respiratory tract disease dying process involves the decline and ultimate failure of (5%).4 In fact, 90% of all American deaths occur from all major organ systems. Depending on the nature of the these or other chronic conditions. Although a slow and contributory disease, this process may take anywhere from progressive deterioration can be disheartening for the several months to several hours. Box 27-1 depicts the patient to experience and challenging for the family to broader progressive changes that occur in the final months observe, a centered presence in the face of impending of life. death optimizes opportunities for meaningful closure. Accordingly, patients can rally when least expected, of- As a patient declines in function, physical therapy ten to fulfill one last important goal. For example, in the intervention can be helpful in providing education, days before his death, Bill, a 70-year-old man with end- adaptive devices, or alternative movement strategies stage brain cancer, decided that he would leave his bed to optimize safe function. These interventions are fully in order to have one last meal at the table with his fam- described in the section on models of physical therapy ily. Physical therapy services were requested and pro- practice in hospice and palliative care further in this vided to help Bill carry out this goal. In other cases, chapter. patients may also linger in an unresponsive state for a period of time, dying shortly after a long awaited loved Of equal importance to providing appropriate inter- one finally arrives. Joseph, a 72-year-old man with liver ventions is working closely with the hospice team to cancer, died the day after his six adult children finally ensure that all forms of pain and discomfort are mini- arrived from their locations around the country. mized. This is important not only for the patient but also for family members who, whenever possible, must The end-of-life process is unique for every individual. be freed of the burden inherent in watching a loved one There are many different ways in which the journey to suffer. In the weeks or days before death, multisystem the end of life begins so that each person dies in his or her own unique way, and in his or her own time.5 BOX 27-1 Progressive Changes in the Terminal Supporting this individual process is the purpose and Phase focus of hospice care. Month 6 Generally, patient is ambulatory, coherent, some In the context of hospice care, approaching death is Month 5 adverse effects from curative measures/ viewed as a physical, psychological, and spiritual event. Month 4 medications, initial stages of grief, anger, denial. Patients and their families require information and com- Month 3 passionate support to assure that their collective needs Month 2 Some weight loss, weakness, symptoms manifested, are honored during this critical time. The interdisciplin- showing signs of stress, growing acceptance of ary hospice approach involves considerable involvement Final terminal state, fear, depression. of the patient’s nurse, who will administer medications month for comfort. The hospice chaplain may be involved for Continuing weight loss, decreasing appetite, spiritual support at the request of the individual or fam- physical manifestations, symptoms more ily, especially when impending death provokes questions pronounced. Grief work, planning, resolving. by the dying person or family members related to the presence of or the prospect of life after death. Trained Physical deterioration apparent, symptomatology hospice volunteers may provide caregiver respite or pro- and pain increase, beginning of withdrawal, vide a reassuring presence at the bedside. The hospice acceptance of terminal disease. social worker may assist the family in a number of prac- tical ways, such as addressing financial concerns. Physi- Progressive physical deterioration, symptoms cal therapy interventions such as edema reduction, increase, pain management primary, may be breathing exercises for relaxation, positioning, and gen- bedridden, increasing withdrawal, resolution tle massage or stretching may be performed in the days and closure. End stage: pronounced withdrawal, requires total care, intensive management of symptoms and pain, no appetite. (Adapted from National Hospice and Palliative Care Organization (NHPCO): Time line phases of terminal care, 1996. Reprinted with permission.)

502 CHAPTER 27  Hospice and End of Life restlessness could be described as a condition involving considerable physiological and psychological pain, decline results in a host of signs, which are illustrated in occuring at all levels of consciousness. Unresponsive Table 27-1 and further described in this chapter. patients may demonstrate terminal restlessness by pull- ing at their bed clothes, making random movements, or It is very common for patients to sleep most of the attempting to remove their medical appliances. Patients time in the days before death. They may no longer be who are more wakeful may repeatedly ask to get up or interested in food or fluid, and family members must attempt to do so without help. They may talk about see- be assured that for the dying person, the process of ing and speaking with deceased friends or family mem- digestion can be uncomfortable or even painful. Further- bers (for example, a patient may sit up in bed and tell more, as death approaches, patients may have increased family members, “They’re coming!”). Understandably, difficulty swallowing. Even in the absence of discomfort, the behaviors of terminal restlessness can be disconcert- dying patients do not need, nor can their bodies assimi- ing for patients and families. Reassurance, support, and late, the energy provided from food. When patients re- skilled pharmacologic intervention, often involving the fuse food and fluids, or in cases where they are use of sedating medications, are important measures that withdrawn in accordance with an advance directive, can reduce the duration and severity of these symptoms. family members need assurance that the patient will not experience hunger or any sense of deprivation. In such “Active death” typically occurs in the final days or instances, the hospice nurse will work with the patient hours and involves observable signs of systemic failure.8 and family to provide medications and other interven- Terminal restlessness may increase. Respirations may tions to ensure optimal comfort. The ethical and legal become extremely irregular and include periods of very aspects of intentional food and fluid withdrawal will be rapid breathing, followed by several seconds of apnea further discussed later in this chapter. (Cheyne–Stokes breathing). Other types of irregular breathing patterns may occur as well, along with “death “Terminal restlessness” is a specific form of delirium rattles” from congested and fluid-congested lungs. Urine and agitation that occurs in the final weeks, days, or output decreases significantly, and the urine may be hours of life. It is very common, although the degree dark. Blood pressure will often drop 20 to 30 points may vary greatly, affecting up to 85% of terminally ill below the patient’s normal blood pressure range, with patients, and includes signs such as restlessness, agita- systolic pressure as low as 70 mmHg and diastolic read- tion, confusion, hallucinations, or nightmares.7 The ings as low as 50 mmHg. This lack of perfusion may experience of terminal restlessness can be highly upset- result in extremities that are very cold, blue or purple. ting for families and patients alike. One patient of the Patients may also complain of numbness in their distal authors described his terminal restlessness as a feeling of extremities. “just wanting to crawl out of my skin.” Terminal rest- lessness is thought to be the result of failing metabolic The patient may be unresponsive, or even comatose. processes occurring as death approaches. In addition, Family members need to be assured that the patient terminal restlessness may be exacerbated by physical hears them as hearing is one of the last senses to fail8 distress from severe constipation, decreased oxygen ex- change, or changes in body temperature. Thus, terminal TA B L E 2 7 - 1 Multisystem Physiologic Signs of Approaching Death System Sign or Symptom Contributing Factors Central nervous Confusion, delirium Hypoxemia from disease process or decreased function, system Disorientation metabolic imbalances such as acidosis, toxicity from Increased time spent sleeping (from a few hours a day to renal or liver failure, pain, adverse effects of opioid Musculoskeletal medication (this may be reversible) Cardiopulmonary most of the day) Decreased levels of responsiveness, eventual coma Progression of disease process, prolonged inactivity Integumentary Anxiety and restlessness, hallucinations or reports of seeing Disease process, organ failure, adverse effect from things, hearing voices chemotherapy (not reversible) Weakness, loss of function, fatigue Respiratory failure may result in fluid accumulation in Drop in blood pressure Heart rate variability and irregularity lungs Breathing rate may be very rapid, alternating with periods of Loss of cardiovascular perfusion Pump failure apnea, or very slow gurgling in chest Loss of muscle tone Cool and clammy skin, distal extremities may be bluish Adverse effects of medications (opioid medications are Edema constipating) Gastrointestinal Loss of interest in food and fluid Constipation or diarrhea Incontinence, decreasing urine output as death approaches

CHAPTER 27  Hospice and End of Life 503 and thus should be encouraged to talk to their loved As stated previously, dying is not only a physical one even if they do not receive a response. In contrast, event. Many patients experience significant psychologi- other patients may be relatively wakeful and able to cal and social signs as well. Table 27-2 illustrates the converse with family members almost to the moment of spectrum of these, along with their possible causes and death. helpful interventions. TA B L E 2 7 - 2 Psychosocial and Spiritual Signs, Symptoms, and Interventions of the Actively Dying Signs and Symptoms Cause/Etiology Interventions Fear of the dying process. Cause of fear will be specific to the individual. Explore fears and cause/etiology of fears, including Fear of the dying process may be Fear of the unknown: how they will die, what physical, psychosocial, and spiritual. greater than the fear of death. will happen during the dying process. Educate patient and family on physical, psychosocial, Fear of painful death and suffering such as and spiritual signs and symptoms of dying process. Fear of abandonment. Most patients do not want to die breathlessness, physical pain, loss of Ask patient/family how they would like the dying mental competence and decision-making process to happen. alone. ability, loss of control, loss of ability to May present as patient anxiety, maintain spiritual belief systems and faith. Normalize feelings. Fear of judgment, punishment related to guilt, Provide reassurance that patient will be kept as pressing call button frequently, and subsequent pain and suffering during or calling out for help at home. the dying process. comfortable as possible. Family members may continuously Fear of being alone. Provide presence and increase as needed. stay at bedside to honor Fear of who will care for them when they are patient wish to not be left unable to care for themselves. Provide reassurance that everything will be done to alone. have someone with the patient. Fear of what will happen after they die: Fear of the unknown. afterlife or cultural/faith system beliefs Provide presence. in relation to death. Explore options for increasing presence around the Nearing death awareness. Patients state they have spoken to Fear that belief systems regarding afterlife will clock, including health care professionals (nurse, be different than perceived and/or lived. social worker, nurse’s aide) and family, friends, those who have already died or volunteers, church members, etc. have seen places not presently Attempt by the dying to describe what they For family member doing bedside vigil, encourage accessible or visible to family are experiencing, the dying process and frequent breaks, offer respite. Family members may and/or nurse. May describe death. also be anxious and need permission from nurse to spiritual beings, bright lights, care for themselves. “another world.” Transition from this life. Exploration of fear. Statements may seem out of Attempting to describe something they Companionship, presence. character, gesture or request. Pastoral care or patient’s clergy for exploration of life, Patients may tell family members, need to do/accomplish before they die, afterlife, faith system beliefs. significant others when they such as permission to die from family, Support cultural and faith system beliefs. will die. reconciliation, see someone, reassurance Do not contradict, explain away, belittle, humor, or Withdrawal from family, friends, that survivor will be okay without them. argue with the patient about these experiences. the nurse, and other health Attentively and sensitively listen to the patient, affirm care professionals: decreased Transition from this life, patient “letting go” the experience, and attempt to determine if there interest in environment and of this life. is any unfinished business, patient needs. relationships and family may Encourage family/significant others to say goodbye, feel they have upset or give permission for patient to die as appropriate. offended patient. Support to family and other caregivers. Educate about the difference between nearing death awareness and confusion, education to family, and other caregivers. Normalize withdrawal by educating family about transition. Presence, gentle touch. Family members may need to be educated, encouraged to give permission to patient to die. Family may need to be encouraged to say goodbyes. (From The Hospice of the Florida Suncoast, 1999. Reprinted with permission.)

504 CHAPTER 27  Hospice and End of Life the dying person. Understanding this as a relatively com- mon but often unacknowledged experience, perhaps One of the many benefits of hospice involvement is because of a societal reluctance to grapple with complex the preparation of the patient and their family about the metaphysical issues, may provide recognition that this is signs and symptoms related to the death process. Such a normal end-of-life process occurring, and afford some preparation dispels inaccuracies (i.e., death is painful), individuals comfort that the dying loved one will not be reducing fear, regret, and guilt over not doing enough for alone after passing away as may be consistent with their their loved one. Most of all, skillful management of personal beliefs. death-related discomfort allows the patient and family to be comfortably and lovingly present to each other Other patients may voice their beliefs about the tim- throughout the process. Finally, when a loved one dies ing of their deaths in ways that may not seem to coincide peacefully in the manner of a “good death,” family with apparent physical parameters. The insights offered members can focus their grief on mourning their loss and by those in our care offer us an opportunity to support finding comfort in their memories. their caregivers and loved ones in helping meet the desire Nearing Death Awareness.  ​A variety of altered mental to have a peaceful death. By listening carefully, then states may be experienced as the end of life approaches. recognizing such communication, physical therapists The “out of body” experience has been reported after can educate family members, allowing them to become brushes with death, such as an accident.9 Others have more intimately involved in this experience of accompa- reported incidents of knowledge of things that they nying their dying loved one and preparing for their own attribute to awareness of another dimension.10 All of this time of bereavement. work recognizes the mystery that surrounds the dying process, which exceeds the physical indicators that medi- AN OVERVIEW OF HOSPICE cal professionals can use to quantify the ceasing of life in AND PALLIATIVE CARE the body. Hospice vs. Palliative Care Callahan and Kelley11 recommend from their years of working with individuals during end-of-life experiences In the realm of end-of-life care, two related terms, that clinical caregivers as well as family members learn hospice and palliative care, are often used. Both terms from close listening and observation of the person in pertain to the optimization of comfort and quality of life their care. Caregivers who do not have an understanding of patients with life-threatening conditions. Although of this communication may experience more anxiety. hospice programs have delivered palliative care for more than 30 years, it is also used in many other settings that The dying person may speak in metaphoric language. focus on the treatment of the chronically, but not termi- For example, imagine this dialogue between a mother nally, ill. As discussed later in this chapter, hospice is a and daughter. specific set of services that is covered by the Medicare Hospice Benefit. Patients admitted to hospice must meet “I need to go home,” states the older patient. “Mom, certain requirements, including a physician-determined you are home. This is your house. See the family photos prognosis of less than 6 months and the acknowledge- on the mantle above the fireplace, and there is your fa- ment that they are no longer seeking curative measures. vorite chair,” replies her daughter in frustration after several repetitions. Could there be another sense of The World Health Organization (WHO) defines pal- home to which she is referring, perhaps even a spiritual liative care as an approach that improves the quality resting place consistent with her life-long beliefs? of life for patients and families facing life-threatening illness.12 Thus, palliative care is broader in scope, includ- Another example of misinterpreting metaphorical speech ing patients at any stage of their disease process, who would be this hypothetical conversation between a father may also be seeking curative treatment. Unlike that for and son. “The door is locked,” declares Mr. Thompson hospice, Medicare does not have a specific “palliative emphatically as he arouses from a lethargic state. His fam- care benefit.” However, Part B may cover services such ily is glad to hear him communicate. Son Robert steps from as poststroke rehabilitation that have palliative compo- the bedside to the sliding glass door across the room. “No, nents (i.e., quality of life, comfort).13 Dad. Look, the door is open,” he responds as he demon- strates the sliding door out to the patio moving freely. In reality, the philosophy of palliative care is nothing Perhaps there is some unfinished business Mr. Thompson new to physical therapists as it relates to preserving needs to address, or his way of indicating that he does not human dignity and maintaining an optimal quality of life believe he is ready to die. whatever the circumstances. The professions’ long his- tory of compassionately enhancing the quality of life for Patients will commonly report seeing things that are all patients is only one of the ways in which we are well not visible to others. Insects, reptiles, or other animals positioned for important contributions in palliative care. may be reported as hallucinations related to the intro- duction or dosing changes of opioid medications but the In many communities, hospice and palliative care ser- visualization of people is worth exploring. Often these vices are offered through the same facility. Reimbursement may be recognizable to the dying individual as previ- ously deceased friends or family members, who are per- ceived as calling and communicating in some way with

CHAPTER 27  Hospice and End of Life 505 for palliative care services is administered through the 60-day periods as long as documentation shows the con- patient’s primary medical insurance, enabling patients in tinued need and appropriateness for services. A patient palliative care to receive coverage for monthly visits from may revoke their hospice benefit if they decide to pursue the hospice/palliative care nursing staff. Patients may re- curative measures.15 Medicare requires that all covered main on palliative services for months or years while seek- services (nursing, physician, psychological, and spiritual ing curative or supportive measures for their condition. support) be available on a 24-hour basis to ensure sup- For example, Edwin, an 84-year-old gentleman with a port and comfort whenever needed. The levels of service stroke, remained on palliative service for 3 years, receiving and types of care covered under the Medicare hospice monthly nursing visits from the palliative care nurse. In benefit are illustrated in Box 27-2 and Box 27-3. addition, Edwin’s wife requested a physical therapy mobil- ity consult. Thus, Edwin received three visits from the The Interdisciplinary Model of Care hospice/palliative care physical therapist for patient and family education in transfer safety. One day, Edwin suf- Today, hospice care involves an interdisciplinary medi- fered a myocardial infarction at home, whereupon his wife cal, psychological, and spiritual approach to the promo- summoned an ambulance. He died at the hospital the next tion of comfort and quality of life in patients with a day. In contrast to Edwin, patients with a progressive dis- terminal illness and a life expectancy of 6 months or ease may transfer to hospice when their condition becomes terminal. At this point, their care is reimbursed through BOX 27-2 Specific Services Covered hospice benefits. by Medicare Hospice Benefit Clinical Scenario.  ​Elaine was a 54-year-old woman with a 2-year history of cervical cancer. During this • Nursing services* time, Elaine had received three courses of chemother- • Physician services to provide palliation and management of the apy, with good results. Elaine sought palliative care services through her local hospice for the purpose of terminal illness and related conditions* expert pain management. She received monthly visits • Medical social services provided by a social worker under the from the palliative care nurse, who assisted Elaine in determining appropriate pharmacologic measures for direction of a physician* pain control. Elaine’s medications were covered by her • Counseling services (chaplain, psychosocial, bereavement)* primary insurance. In the meantime, Elaine underwent • Home health aide services an additional course of chemotherapy, and this episode • Homemaker services left her considerably weaker than prior courses. As a • Medical supplies result, Elaine was unable to engage in her aerobics • Drugs related to the care of the terminal illness classes at her local gym. A physical therapy consult was • Durable medical equipment requested to assist Elaine in modifying a fitness routine. • Any other medical supplies The physical therapist worked with Elaine to develop a • Physical therapy, occupational therapy, and speech therapy if slowly progressive walking program, using a pedometer to measure her progress. Elaine remained on palliative indicated services for an additional 8 months, whereupon her • Laboratory testing and other diagnostic studies related to the physician determined that further curative measures were unlikely to be successful. Elaine transferred to care of the terminal illness hospice and received services for another 2 months before her death. *Denotes core service required for Medicare reimbursement. The Medicare Hospice Benefit BOX 27-3 Levels of Care Provided by Hospice Benefit The Medicare hospice benefit was enacted by Congress in 1982 and since that time has been the major source of Home-Based Care payment for U.S. hospice services. In 2007, Medicare 1. Routine Home Care: Patient receives hospice care at the place he provided services for 84% of all patients served.14 In order to qualify for hospice, a physician must provide or she resides. certification of a terminal condition with a prognosis of 2. Continuous Home Care: Patient receives hospice care consisting less than 6 months. In addition, patients must certify that they are no longer seeking curative measures for predominantly of nursing care on a continuous basis at home. their condition. Finally, patients must be entitled to Continuous home care is only furnished during brief periods of Medicare Part A services (inpatient). Patients who elect crisis and only as necessary to maintain the terminally ill patient the Medicare hospice benefit begin with two initial at home. 90-day periods, which can then be followed by unlimited Inpatient Care 3. General Inpatient Care: Patient receives general inpatient care in an inpatient facility for pain control or acute or chronic symptom management that cannot be managed in other settings. 4. Inpatient Respite Care: Patient receives care in an approved facility on a short-term basis in order to provide respite for the caregiver.

506 CHAPTER 27  Hospice and End of Life Consultative Medical professionals director less. Medicare-certified hospice facilities require the PT, OT, SLP (physician) involvement of several distinct health professionals pharmacists who comprise the interdisciplinary team (IDT). These (as needed) Patient’s professionals represent four domains of care that include primary (1) physical (physician and nurse), (2) functional (con- physician sulting therapists, nurses, and nurse’s aides), (3) interper- sonal (social workers, psychologists, and counselors), Volunteer Patient Nurse and (4) spiritual (chaplain, psychologists, and social coordinator and (RN, nurse workers).16 Coverage for core services, medications, and practitioner) equipment is provided to Medicare-certified hospices Hospice family through a specified daily, or per-diem, rate. As of April volunteers 2009, Medicare reimbursed hospices at a daily rate of $140.15 for each patient receiving routine home care, Spiritual care Certified $817.26 for continuous home care, and $622.66 for in- professionals nursing patient hospice care.17 Volunteers, who complete a com- assistant prehensive training course on the philosophy of hospice, Psychosocial Home health are an important element of each domain of hospice professionals care. Accordingly, volunteers assist with light housework (social worker, aide or meal preparation. They can also provide supportive psychologist) companionship for patients and family members. FIGURE 27-1  T​ he interdisciplinary hospice team. Physical therapists are not a required “core service” on the hospice IDT, meaning that Medicare does not the status of each patient and his or her support system. require their services to be provided for all patients. The patient and his or her family members may also Rather, physical therapists are part of a group of profes- request the option to attend the IDT. sionals (including occupational therapists and speech– language pathologists) who must be made available to The IDT model of hospice care prevents many of the any patient on an “as needed” or “consultative basis.” communication pitfalls that can impede quality of care Thus, the Medicare hospice benefit includes coverage for and create patient dissatisfaction. By the thoughtful physical therapy provided in a hospice setting on coordination of every aspect of care, patients and their a consultative basis. This policy is supported by the families can have every element of their quality of life 2008 Medicare Conditions of Participation for hospice addressed at a time when it is most needed. Because (section 418.92), which was revised to include the fol- physical therapists are not considered a core member of lowing language: “Physical therapy, occupational ther- the IDT, they may not feel that their presence at the apy, and speech–language pathology must be— weekly meetings is appropriate or necessary. However, it has been the experience of these authors that a con- 1. Available, and when provided, offered in a sistent presence at weekly IDT meetings is invaluable manner consistent with accepted standards of for educating team members about the value of our practice; and services. In addition, we can identify patients who could benefit from a physical therapist examination 2. Furnished by personnel who meet the qualifica- and intervention. tions specified in part 484 of this chapter (individuals who are licensed in the relevant Case Scenario.  A​ licia was an 86-year-old woman disciplines).”17 who was admitted to hospice after a series of several strokes that resulted in failure to thrive. Alicia had a Although this mandate suggests that physical therapy is long prior history of back pain that had recently exacer- an important component of the IDT, individual hospice bated. At the IDT meeting, a long discussion ensued programs must develop their own guidelines for our inclu- about appropriate options for pain control, as Alicia sion. Research is currently underway to help determine wanted to avoid sedation as much as possible. At that these guidelines as well as to support the cost-effectiveness point, the physical therapist suggested a trial of transcu- of physical therapist inclusion as a core service on the IDT. taneous electrical nerve stimulation (TENS), describing Figure 27-1 illustrates the disciplines that comprise the IDT. the use and benefits of this modality in the treatment of Interdisciplinary Team Meetings.  ​The Medicare Condi- back pain. The team agreed that a trial of TENS might tions of Participation17 mandates that each patient in a provide Alicia with a nonsedating approach to pain con- Medicare-certified hospice receive an interdisciplinary plan trol. A physical therapy consult was initiated and TENS of care at the time of admission, which must be updated turned out to be a successful pain control option for by the team at least every 2 weeks. Thus, most hospices Alicia. hold weekly IDT meetings, which facilitate the coordina- tion of care for both new and existing patients. The reports of each core discipline provide a comprehensive picture of

CHAPTER 27  Hospice and End of Life 507 History of Hospice Care annual Facts and Figures on Hospice Care20 reported that of the 2.4 million U.S. deaths occurring that year, The term hospice derives from the Latin term hospitum, 930,000 (38.8%) occurred in a hospice setting. Further- which originally described a place of shelter for sick and more, 1.4 million Americans received hospice services weary travelers. Nirmal Hriday (Pure Heart), one of the during that time. Interestingly, 220,000 patients (15.7%) first known homes for the dying, was established in 1952 were discharged from hospice, either because of an by Mother Teresa in Calcutta, India.18 Working in the extended prognosis or a desire to pursue curative mea- most destitute slums of Calcutta, she and her sister nuns sures. This is a noteworthy statistic, which dispels the took indigents who were dying off the streets to nurse misperception that hospice is an irrevocable or predict- them at this home, enabling “persons who lived like ably ominous choice for patients with terminal illness. animals to die like angels, loved and wanted.”18 This noble work continues today in more than 500 worldwide The ability for patients to choose where they die is a centers. major tenet of hospice. For 70% of Americans, their own home is the setting of choice.21 In 2002, only 25% Dame Cicely Saunders, MD (1918-2005), is recog- of patients achieved their preference. The concept of nized as the founder of the modern hospice movement. hospice care as the setting of choice for the support of As a nurse working at an English cancer hospital after advance directives has also begun to emerge. Accord- World War II, she was disturbed by the pain and isola- ingly, the number of clients served by hospice each year tion she witnessed among dying patients. These observa- has grown by approximately 10% each year between tions compelled her to enter St. Thomas’s Medical 2005 and 2009.20 Furthermore, 70% of the 930,000 School in 1951 at the age of 33, qualifying as a physician patients who died under hospice care in 2008 were able in 1957. to do so in their primary place of residence. Of this 70% who died in their primary residence, 42% of deaths oc- Following the completion of her medical studies, curred in private residences, and 22% in nursing homes. Saunders sought additional training in pharmacology, These statistics are one important outcome measure that when she explored the effective use of analgesic medica- supports the value of hospice care in meeting the needs tions for the treatment of pain at end of life. In an of dying patients.20 environment where medication underutilization was common because of fears of addiction, she challenged Profile of Hospice Patients rationales that were grounded mainly in conjecture. Accordingly, instead of requiring patients to wait until According to 2008 outcome data from the National their pain medications wore off before requesting an- Hospice and Palliative Care Organization, 54% of all other dose, Saunders advocated medicating at a level to hospice patients were female. The vast majority (83%) of produce continual analgesia and wrote several papers these hospice patients were age 65 years or older.20 Thus, that described and provided support for her approach. hospice is and will continue to be primarily a geriatrics Furthermore, instead of the sterile and lonely hospital treatment setting, with numbers increasing significantly rooms where she had worked as a young nurse, Saunders with the aging of the baby boomer generation. proposed treating dying patients in a warm and comfort- able setting with a home-like atmosphere. In 1967, Currently, hospice patients are overwhelmingly Cau- Saunders opened St. Christopher’s Hospice in London casian (83%). The existence of racial and ethnic dispari- where she put her vision into action.19 Saunders served ties in end-of-life care has been confirmed in several as the medical director of St. Christopher’s until 1985, studies.22,23 A systematic review of 13 retrospective co- and was awarded England’s Order of Merit in 1989. By hort studies found statistically significantly lower hos- the time she died in 2005, at the same hospice she estab- pice utilization rates among African Americans com- lished, there were more than 8000 hospices worldwide. pared to Caucasians.22 Another retrospective study examined Medicare hospice database records of 40,960 The U.S. hospice movement began in 1974 upon the Caucasian, Hispanic, African American, and Asian ben- opening of the Connecticut Hospice in Branford. Many eficiaries who received services for end-stage cancer be- of Cicely Saunders’ original ideals have been successfully tween 1992 and 2001.23 The results of the study showed integrated into current hospice practice, contributing to that Caucasians had the highest hospice utilization rate the hospice movement’s significant growth and making it (42%) followed by African Americans (37%), Hispanics the preferred approach to end-of-life care. (38%), and Asians (32%). The study also found that Growth of Programs and Services.  ​Since the incep- nonwhite groups had higher numbers of hospitalizations tion of hospice in 1974, the number of American hos- for longer periods of time as well as a higher likelihood pices has steadily grown, numbering 4700 in 2008.14 of an ICU admission in their last month of life. Finally, Hospice services are delivered through a variety of members of these nonwhite racial groups were also more facilities that include freestanding facilities (58%), pro- likely to die in the hospital.22 The reasons for these grams in home health agencies (20%), or units attached ethnic and racial disparities are not yet clear, and further to hospitals (21%) and nursing homes (1%).20 In 2008, research is needed to explore the impact of cultural the National Hospice and Palliative Care Organization’s

508 CHAPTER 27  Hospice and End of Life comfort measures. As patients with end-stage dementia enter the hospice system in increasing numbers, further differences, belief systems, and patient preference on se- guidelines may need to be established to determine ap- lections related to end-of-life care. As the American propriate indications for pain control and comfort as they population becomes increasingly diverse, health care approach end of life. Because the burden of caregiving can professionals may need to explore culturally sensitive be considerable in such cases, hospice staff can also pro- approaches for educating patients of different racial and vide assistance to family members so that patients can ethnic backgrounds about the value of hospice care. remain in their homes during this process. Diagnoses.  T​ he major diagnostic categories of the Length of Stay.  T​ he average length of stay for patients patients seen in U.S. hospices during the years 2006 and in hospice in 2008 was 67 days.20 However, 30% of 2007 are shown in Table 27-3. An interesting trend with patients died or were discharged in 7 days or less, and respect to these diagnostic categories is the increasing 13% died or were discharged in 180 days or more. This number of patients with Alzheimer dementia and debili- statistic indicates that overall, patient survival is well tation. Currently it is estimated that 5 million Americans within the Medicare requirement of an expected progno- are living with Alzheimer’s disease, and projections are sis of 6 months or less. Furthermore, it indicates that a as high as 16 million by 2050.24 Patients with this dis- majority of patients and families receive services long ease may survive and deteriorate for a period of years enough to benefit from hospice’s compassionate and while their family members struggle to provide care. expert approach to comfort measures. As patients with Alzheimer’s disease become more de- It can be emotionally difficult for family members bilitated, they may ultimately develop a host of conditions when admission to hospice is delayed in light of a compel- that are considered indications of the end stage of the ling need. This can occur when lack of health care pro- disease. In order to be considered for hospice coverage, vider awareness precludes a timely referral, or when the Medicare guidelines require patients with Alzheimer’s disease process becomes so acute that the patient dies in disease to exhibit at least one of the following signs in the the hospital. In an illustrative case, Cheryl, an 83-year-old previous 12 months: muscle wasting and malnutrition woman with ovarian cancer was admitted to the hospital (inanition) with a 10% decrease in body weight, septice- with severe pain. Her attending physician, perhaps fearing mia, decubitus ulcer, aspiration pneumonia, recurrent fe- the possibility of an overdose, refused to prescribe opioid ver, or urinary tract infection.25 Unfortunately, by the time medications at the level needed for analgesia. When they qualify for hospice care under the current guidelines, Cheryl’s son arrived from another state 2 days later, he many patients with end-stage Alzheimer’s disease are arranged for Cheryl’s immediate transfer to a hospice completely dependent in all care and show significant residence where she died only hours later, still without cognitive impairments. The extent of these impairments adequate pain control. Cheryl’s case raises troubling ques- can challenge caregivers, especially in the realm of deter- tions. How can health care providers be better educated mining patient needs for pain medications and other about the value of hospice services? How can candidates for hospice services be identified in a timelier manner? TABLE 27-3 Diagnostic Categories of Patients What are sources of barriers to effective pain control at Admitted to U.S. Hospice Programs, end of life, and how can they be mitigated? As the conse- 2006-2007 quences of the economic downturn of the late 2000s unfold, it will be important to identify any additional Primary Diagnosis 2007 2006 barriers to timely hospice admission. (%) (%) Hospice Outcomes Cancer (malignancies) 41.3 44.1 Noncancer diagnoses 58.7 55.9 Data on hospice outcomes are slowly emerging and Heart disease 11.8 12.2 showing promising results. One of the most encouraging Debility unspecified 11.2 11.8 outcomes, from a study of 4493 patients, indicates Dementia, including Alzheimer’s disease 10.1 10.0 that admission to hospice prolongs life by a mean of Lung disease, including chronic obstructive 7.9 7.7 29 days.26 The authors of this study suggested that the reason for this finding was the administration of ade- pulmonary disease 3.8 3.4 quate pain control and its favorable impact on enhanc- Stroke or coma 2.6 2.9 ing comfort and quality of life. Kidney disease, including end-stage renal 2.3 2.0 Another promising trend is that hospice care is a cost- disease efficient approach to reducing Medicare expenditures, Motor neuron diseases, including 2.0 1.8 25% of which have been reported to occur in the last 0.6 0.5 year of life.27 A recent study from Duke University re- amyotrophic lateral sclerosis 6.5 3.7 ported that the use of hospice services reduced Medicare Liver disease expenditures by $2309 during this same time period.28 HIV/AIDS Other diagnoses (Courtesy of National Hospice and Palliative Care Organization.)

CHAPTER 27  Hospice and End of Life 509 As a further testimonial to the benefits of hospice Likely their pain management has been poor. Initial nurs- care, recent outcome data from the National Hospice ing care may improve symptom control so that for the and Palliative Care Organization indicates that in 2008, first time in many weeks or months, the person may orders for do not resuscitate (DNR) were respected feel like he or she might be able to make some headway 100% of the time, patient wishes to avoid hospitaliza- toward a stronger and more functional state. Physical tion were honored 98% of the time, and in 73% of therapy at a traditional frequency of two to three times cases, pain was brought to a tolerable level within each week might be more than the person can tolerate, 48 hours of hospice admission.29 At the current time, and is often considered cost-prohibitive in the per diem there are few studies examining the interdisciplinary role reimbursement model of a hospice benefit program. An and outcomes related to physical therapy intervention in alternative model is a slowly progressive modified “reha- hospice. This may be partially explained by a general bilitation light” program that provides exercise and func- lack of awareness among consumers, health care provid- tional training during each weekly or biweekly visit. ers, and even hospice personnel about the value of our Activities can include targeted strengthening exercises that services. It is encouraging that the Hospice Patients minimize the number of exercises and functional activities Alliance (www.hospicepatients.org), a national resource such as a timed sitting program or other ambulation activ- center for hospice patients, families, and caregivers, ity that provides both increased strength and endurance as describes (and promotes) physical therapy interventions well as improved quality of life. Home exercise program for the improvement of safe mobility, reduction in pain, follow-through is an essential part of this approach. Prog- and determination of appropriate equipment needs on ress toward goals may be extremely slow, though measur- their website. Materials such as these can help improve able, over a few weeks or even several months. The reha- awareness of the role physical therapy has in optimal bilitation light approach uses the skilled care of the end-of-life care. Fortunately, an increasing number of therapist in providing timely and appropriate exercise hospice websites are now posting information on physi- instruction and functional training, and it works within cal therapy services. the hospice framework emphasizing quality of life despite a terminal diagnosis. Close contact and communication Areas of physical therapy intervention in hospice have with the interdisciplinary team is vital to ensure all team been described in a few studies and considerable agree- members recognize and concur with this approach to ment among them suggests that pain control, relaxation, care, as it may initially appear to conflict with the hospice respiratory care, and mobility are the major areas of goal of acceptance of a natural death. The following case focus.6,30-35 These interventions are discussed next. scenario illustrates the use of the rehabilitation light approach. MODELS OF PHYSICAL THERAPY Case Scenario.  ​Thelma, age 78 years, was discharged PRACTICE IN HOSPICE from the hospital with end-stage renal disease, and AND PALLIATIVE CARE begrudgingly chose hospice, as the only alternative offered was to begin dialysis three times a week. She Advanced and progressive disease requires a different faced multiple other conditions, including chronic ob- orientation to goal setting and treatment than care for structive pulmonary disease, diabetes, obesity, an in- those who are likely to regain a premorbid level of func- dwelling catheter, osteoporosis, and a fractured metatar- tion. Dietz identified palliative care strategies in patients sal, but maintained a lifelong outlook that she would with cancer, recognizing the need to address ongoing overcome these conditions. She accepted hospice care, problems and minimizing complications.36 Briggs37 fur- but did not plan on dying. Initially bed-bound, and on a ther defined models of care in the palliative spectrum by pressure-relieving mattress because of her inability to integrating the framework from the Guide to Physical reposition herself, she tolerated minimal exercise, but Therapist Practice38 in response to a variety of reim- wanted to know what she could do to work toward the bursement structures. Briggs’ models include rehabilita- goal of getting out of bed to the commode. Beginning tion light, rehabilitation in reverse, case management, with a sitting program in the semielectric bed, within a skilled maintenance, and supportive care. As the models month she was able to sit at bedside. Each day she are described, keep in mind that they are not necessarily worked on her own on a few basic exercises with the exclusive of one another and may be used together or in support of her granddaughters. At each weekly visit she succession as a framework to support important inter- was able to do more, like come to stand and then trans- ventions of end-of-life physical therapy practice.39 fer with less assistance as her foot pain subsided to allow more weight bearing. By the end of the second month, Rehabilitation Light transfers with family assist to the commode or wheel- chair were happening almost daily, though actual sitting Some patients are admitted to hospice care after a long tolerance was less than an hour. After continued work course of disease and uncontrolled symptoms, or when in standing for strength, balance, and self-support experiencing the adverse effects of treatment interventions with weight shifting, Thelma took several steps with a such as chemotherapy, surgery, or radiation treatment.

510 CHAPTER 27  Hospice and End of Life household and garden chores. Some unsteadiness in the yard one day made the IDT and family concerned about front-wheeled walker by month 3 and declared, “I want the possibility of falling and a physical therapy referral to be able to walk out to the kitchen so I can enjoy a was made. Frank’s lower extremity strength was de- cigarette.” Slowly, progressive gait training ensued, fol- creased, with significant muscle atrophy visible although lowed by instruction of caregivers to assist with limited his gait appeared symmetrical. However, any challenge ambulation, with a wheelchair following. By 6 months, or advanced balance activity revealed unsteadiness. He she had achieved her goal as well as transfers with a tub was willing to accept a standard cane, after a trial and transfer bench and wheelchair negotiation of a ramp to instruction in several alternative assistive devices. A the yard. Physical therapy goals had been met with therapy visit frequency of two to four times a month was Thelma reaching her maximum potential, and she was established to follow his adaptations. Within a week he shortly discharged from hospice, to live another 2 years. requested a quad cane, which was properly fitted. He This case demonstrates how physical therapy interven- was instructed in the quad cane’s use within his home, tion can help achieve a person’s desired outcome by on the steps to the driveway, and about his shop. Frank using restorative therapy principles within the palliative declined any exercises, stating his preference was to care model of the hospice care environment. spend his time and energy doing what he loved most. By the end of a month, it was evident that bilateral support Rehabilitation in Reverse was needed as he walked about with the cane in one hand while constantly reaching for support on the near- Traditional rehabilitation progresses a person from a est wall or furniture. A trial of a front-wheeled walker lower to higher level of functional ability. Rehabilitation was offered, providing new freedom, despite some diffi- in reverse is the utilization of skilled patient training and culty in navigating about his favorite spots. instruction to caregivers as a person moves through the transitions from an independently mobile level to a more His wife and daughters watched over him with con- dependent one as the disease progresses and as strength cern as they could see his continued weight loss and and balance wane. Transfers may also become increas- declining energy level. Within the second month, a sec- ingly difficult, necessitating the use of equipment (wheel- ond near-fall occurred, making it apparent that the chair, bedside commode, shower bench) and the assis- options of having a family member provide contact tance of another person. Eventually, bed mobility may assist, or use of a wheelchair would become necessary. require assistance for positioning and comfort, and de- This transition required more instruction, and significant termination of the proper bed surface for skin pressure discussion of his physical course. Soon Frank was spend- management. Throughout this course, the physical ther- ing almost all of his time sitting, and the wheelchair apist can use his or her skill and knowledge of optimal became his more ready companion. Moving from sitting ways to move and assist, allowing the patient and family to standing was becoming more difficult, so instruction to negotiate this transition toward the end of life. By was provided to Frank and his family on his wheelchair being able to problem-solve function dilemmas and setup and body positioning for a transfer, as well as as- anticipate the loss of activities, the physical therapist can sistance techniques. His reluctance to use a bedside com- enhance the family’s ability to adjust along an unpredict- mode required an increasing number of transfers able course of decline and prevent unsafe conditions throughout the day and night, a strain on all involved. resulting in falls or caregiver injuries. At each new func- Frank was preparing to let go, as his sense of meaningful tional level, the therapist might consider what are the participation in life was ebbing. A sudden change in level short-term goals for the visit, in light of the long-term of awareness and physical status required family training hospice goal of a safe and comfortable patient-directed on bed positioning and turning for pressure relief. After death at home. Frequency for such care may be quite 3 days of intermittent consciousness, Frank died in his variable, and the use of PRN (as needed) visits can be own bed, with his wife and two daughters nearby. appropriate. Regular communication with the patient, family, and other hospice IDT staff may help identify This case illustrates the type of effective care a physical when visits are needed. The following case scenario therapist can provide in the face of a terminal diagnosis illustrates rehabilitation in reverse. and declining mobility, rather than the traditional care of Case Scenario.  ​Frank, age 84 years, developed back expecting participation in progressive-resistive exercise and abdominal pain while traveling in a recreational to achieve goals of enhanced mobility. Interestingly, the vehicle one summer and eventually was diagnosed with patient and family’s acceptance of Frank’s impending advanced adenocarcinoma. Frank and his family decided death made this approach feasible and appropriate. not to pursue treatment but rather to try to enjoy the remaining time they had together, at home. When Frank Case Management was admitted to hospice, nursing was able to manage his pain while social work fostered family support, with Case management is a frequently used model of care for daughters traveling for respite and help when needed. nursing and physical therapy in many specialty clinics to Frank had been losing weight but had been active doing provide long-term, ongoing care for challenging and

CHAPTER 27  Hospice and End of Life 511 changing conditions such as amyotrophic lateral sclero- and facilitating a safe and comfortable patient-directed sis, spinal cord injury, amputation, and diabetes. In death. home health, case management is used to provide similar follow-up, care, and instruction for people with compli- Skilled Maintenance cated care, multiple comorbidities, and unskilled or multiple caregivers.40 This model is useful in palliative When a patient must perform an activity that is medi- and hospice care as well. With a person who is relatively cally necessary, skilled maintenance has been identified stable though gradually declining over weeks or months, for use under Medicare home health guidelines.40,41 periodic reevaluation can identify physical and func- In traditional home health situations, care that might, tional changes that need to be addressed to prevent under usual circumstances, be taught to a caregiver may complications. Interventions can include instructing the require skilled physical therapist intervention because of caregivers in providing optimal assistance, updating the specific complexity. An example might be the perfor- home exercise program, and outlining problems that mance of range of motion to a joint proximate to an might be anticipated. Monthly or bimonthly visits with unstable fracture. In hospice, skilled maintenance is used appropriate instruction and follow-up intervention can to perform an important functional activity, which the accomplish this end. The case of Evelyn illustrates case patient is no longer able to perform alone or with a fam- management. ily caregiver, yet can complete with the assistance of the Case Scenario.  A​ t 94 years, Evelyn retained a regal physical therapist. For example, because of extensive demeanor, sitting in her chair holding court with four weakness, tone or balance deficits, or caregiver limita- generations of offspring attending to her, although she tions, a therapist may be needed to provide help with did not allow much to be done for her. With end-stage ambulation or bed transfers. Under hospice rules, when heart disease as an admitting diagnosis, along with osteo- these activities provide for significant quality of life, they arthritis, cataracts, and hearing loss, life had become a are considered skilled care. Consultation with the IDT is challenge. She insisted on doing almost everything her- important to establish a care plan that provides for the self, despite exerting high levels of energy expenditure. frequency needed, as well as patient and family support An initial physical therapy visit offered recommendations through the process of letting go of activities during the to make the environment safer and easier to move course of care. around, and adjust her equipment for improved comfort Case Scenario.  R​ oger, age 74 years, was a retired and efficiency. Monthly visits were scheduled to reassess rancher and businessman. His life was changed with the her safety and mobility, and to instruct various caregivers diagnosis of an astrocytoma, and the resultant physical in different ways to assist as Evelyn’s condition became trauma of brain surgery to resect the tumor, radiation more fragile. Begrudgingly she allowed more help with treatments, and the array of medications to control bathing, dressing, and other tasks. seizures, swelling, and other adverse effects. He was eventually admitted to hospice, and a physical therapy Because sitting was her primary position of comfort consult was initiated because the patient’s wife was hav- both day and night, skin integrity and pressure relief ing difficulty helping him transfer because of the dense concerns were addressed. Adapting her chair to an left-sided paresis and spasticity he experienced. The pri- optimal height with the fabrication of a platform mary focus of physical therapy was problem-solving underneath the entire chair elevated the seat height environmental challenges and transfer techniques to while maintaining the other comfort features and elim- allow his petite spouse to assist with the patient’s trans- inated the instability of multiple cushions. She enjoyed fers to every surface. doing some exercises while she sat, if someone did them along with her, and the family was more than willing to In conversation, it became clear that Roger’s sense of comply. Her family’s concerns about potential falls self had been dramatically affected by confinement to a were discussed repeatedly and at length in the context chair. What he missed more than anything was being of physical limitations, quite variable patient willing- able to walk about his home and gaze through the ness to have assistance or use devices, and Evelyn’s windows at “his spread.” A trial of gait with a hemi- right to self-determination. Evelyn was under hospice cane, a plastic ankle–foot orthosis, and gait belt on the care for 8 months, long enough to celebrate her next visit revealed Roger’s ability to walk up to 50 feet 95th birthday. Just a week later, her daughter found her with help to maintain balance, weight shift, and control in her chair one morning, having expired peacefully the advance of his left leg during swing phase. He was during the night. elated at this recovered ability, and his physical therapist decided with the patient that it could become a part of a Traditional physical therapy might have been offered weekly physical therapy visit. Other issues arose, includ- on a very short-term basis to achieve a specific short- ing travel plans to a national rodeo and training other term goal and then the patient would have been family caregivers. discharged as she did not have rehabilitation potential. However, under hospice, supportive, palliative care As the disease progressed, Roger lost the ability to can be provided, easing the transition to dependency walk, even with assistance, but was able to stand at the

512 CHAPTER 27  Hospice and End of Life part of their end-of-life care, choosing only to participate in activities that provide quality of life—a decision that counter with support to look out over land he loved. The must be respected by the therapist. opportunity to continue being mobile until it was no longer possible, even with assistance, gave meaning to The limited physical capacity that may be present in his existence. a chronically debilitated person can guide us toward the use of “rehabilitation light” as previously discussed. Supportive Care Focusing the exercise program on maximum strength outcomes with a limited number of exercises can en- Supportive care is often provided throughout the course hance success. Recent evidence indicates that a home of care, and is comprised of the psychosocial support exercise program for people older than age 65 years with associated with end-of-life process, as well as physical two exercises results in a better performance outcome measures. The frequency of supportive care measures is than with eight exercises.45 variable. Physical measures may include range of motion and massage. Physical therapy pain management tech- All exercise should address functional goals46 and niques should coincide with the frequent use of a medi- thus be directly seen by the patient as a means to an end, cation regimen by nursing. Some mechanical pain that is rather than something to keep them occupied. Positively not treatable with even high levels of opiates can be reinforcing experiences gives feedback that will provide diminished using a physical therapist’s knowledge of the best outcome. If the patient feels overwhelmed or biomechanics and positioning. experiences significant delayed-onset soreness following activity, it is likely that the decreased quality of life Pressure relief becomes an issue with progressive satisfaction will inhibit further participation.47 weakness, decreased mobility, insufficient nutrition, and fragile skin. Both seating and bed surfaces should be Even patients with severe chronic obstructive pulmo- considered in order to manage a failing body’s integu- nary disease have been found to benefit from a biweekly mentary system. A more complete discussion of these supervised home exercise program over a 4-month clinical supportive care measures follows in Clinical period, with a 3% gain as opposed to 28% deterioration Issues. in the nonexercising control. These results are not over- whelming evidence of the effectiveness of exercise train- CLINICAL ISSUES—CONSIDERATIONS ing, but the patients in this study belong to a severely FOR CARE disabled population with a progressive disease and a grim outlook.48 As with the models for practice in hospice and palliative care, the circumstances of declining function and often Measuring resting heart rate (RHR) and activity- very limited performance status demand the attention of related heart rate is useful in determining physical perfor- the physical therapist to reexamine elements of clinical mance status, when related to the predicted maximum practice in this light. Subtle changes in the way knowl- heart rate (age-adjusted maximum HR) (using 220 – age, edge is used and clinical skills are applied can or less, or 220 – RHR 3 exercise level). With a failing result in substantially improved short-term outcomes for body, resting heart rate may be much higher than 100 those individuals in the last stage of life. beats per minute. A 75-year-old man with a predicted maximum heart rate (PMHR) of 145 and a RHR of The Role of Exercise 120 is already performing at more than 80% of maxi- mum (82%). After walking 30 feet to the bathroom using Exercise plays a critical role in maintaining strength to a wheeled walker, he nearly collapses with a HR of 144, allow adequate functional mobility for quality of life. more than 99% of PMHR. This adverse event represents When determining the appropriateness of exercise for a not only a significant fall risk from collapse but also an body that is failing at the end of life, the cause of the effort comparable to that of a sprint performance on a weakness should be considered to determine if increased running track. An explanation of this relative maximum strength is possible and/or realistic. Weakness that can aerobic effort is often affirming to the patient and reassur- be reversed may be caused from chemotherapy or radia- ing to the family. Similarly, patients with progressive tion therapy,42 prolonged hospitalization,43 or a period weakness and muscle atrophy will experience difficulty of immobility or forced bed rest.44 moving from sitting to standing, especially from their favorite chair. Physical therapists have a critical opportu- The client’s prior exercise and fitness history is also nity to educate patients, their families, and their caregivers significant.45 A person with substantial prior participa- regarding maximal physical capacity for anaerobic muscle tion in some strength and endurance activities will contraction and the work that is done just to move from respond in a different way than someone who has never one position to another. Sharing these examples with both participated in exercise as a lifestyle behavior. Ability to patient and family can lead to an affirmation that per- differentiate effort, fatigue, and workload from soreness ceived exertion is extremely high while in the process of or pain will play a role in performance and success as decline and also some recognition of the effort it takes to well. Some patients will decline an exercise program as accomplish even the smallest of tasks.

CHAPTER 27  Hospice and End of Life 513 In conclusion, it is important that the physical therapist situations. Positioning and wrapping with short stretch offer the option of specific exercises and activities that are bandages also may be helpful to reduce limb size, and both accomplishable and meaningful to the patient’s make it easier to allow easier functional mobility with life condition, along with education that puts exercise unweighted limbs.51 By demonstrating these techniques and physical performance in the perspective of physical effectively and teaching the caregivers to follow a modi- changes toward the end of life. If such a program is well fied program that is not overly taxing of the family, integrated into a daily routine, the optimal understanding caregivers can be taught by a physical therapist to pro- and outcomes will be achieved. vide a successfully satisfying activity with their loved one. It is understood and should be explained that in Equipment and the Environment some cases the efforts to control edema may fail because of the body’s system failure, and this is not a failure of The ability to move from sitting to standing may require the caregivers. Despite this eventual outcome, comfort greater effort or assistance with increased weakness. from the touch of massage may still be enjoyed. Adapting a favorite recliner chair to an optimal height can be achieved by instruction to the family in fabrica- As is discussed in the earlier section on Nearing Death tion of a platform underneath the entire chair, often of Awareness, end-of-life experiences may include a sense 4 to 6 inches. This elevates the seat height, maintains the of “needing to go,” as the person undergoes transitional other comfort features, and eliminates the instability of changes and separation. Younger and more able-bodied multiple cushions. Some families may choose to pur- patients can become very restless, and walk or pace end- chase an electric lift recliner as another option. Other lessly. This phenomenon becomes a more challenging equipment in the home such as a bedside commode or management problem if the terminal restlessness occurs shower bench might need to be elevated accordingly. in someone unable to get up from bed safely.52 Thera- peutic techniques such as holding and rocking (in bed or Energy conservation can be of great significance, as at the bedside) may be used, and also taught to caregiv- patients are often performing at near maximal energy ers as a way to provide the physical and vestibular sensa- output levels and fatigue rapidly as noted earlier. Stan- tion of movement and the “going” that is so keenly dard measurement for walker heights allows for signifi- desired.53 This is an excellent adjunct to the medications cant elbow flexion. In younger populations and people frequently offered by the hospice team to control this with adequate strength, the energy costs of this upper symptom. extremity use may be easily within their ability. In tests of upper extremity forces with variable walker Range of motion is another intervention that must heights while maintaining a stressful lower extremity be considered from a different perspective. Range of non–weight-bearing status, evidence shows that more motion may be provided to maintain enough range to complete elbow extension can reduce elbow force allow for personal care or limiting finger flexion to pre- moments.49 With the older adult in terminal decline, vent palm injury. If movement is painful, range of adjusting a walker height to allow almost complete motion should be limited to this practical standard. elbow extension can provide energy savings that will Some people may very much enjoy the stimulus of hav- allow safer and easier ambulation for an extended time ing their otherwise immobile and understimulated limbs during their illness. moved for comfort. With proper instruction, caregivers or other volunteers may be able to do passive or assistive Comfort Care Measures range of motion regularly. Another application of range of motion in end-of-life care is to provide the gentle Comfort care of the terminally ill has risen to the fore- stimulus of passive, assistive, or active movements of the front with increased awareness of the physical and lower extremities, along with the verbally guided visual- psychosocial variables that affect and accompany the ization images of a favorite walk that the person might process.50 One of the primary goals of end-of-life care have enjoyed (e.g., to a park, the ocean, or community through hospice is pain relief and comfort. Physical locations). This “walking together” can provide the therapy has much to offer through appropriate direct patient and caregivers with a sense of doing something interventions and the education and training of family purposeful and pleasurable as they reflect on their mem- caregivers. ories and life closure issues together. Edema is a frequent symptom as the body fails, Understanding the nature of falls, as discussed else- whether from adverse effects of treatment (surgery and where in this text, is important during the decline at end radiation), decreased mobility and stasis of position,51 or of life. Many of the changing physical parameters will failure of body systems as disease progresses. Swollen increase fall risks. These risks can be magnified by the limbs can become extremely uncomfortable from person’s ego and desire to maintain independence. Engag- the internal pressure on sensory receptors. Manual ing the patient and family in discussions of this disparity lymphatic drainage and other massage techniques can of physical ability and desire can lead to informed deci- provide temporary and longer-term relief in many such sion making to solve this dilemma and make for a safer environment of care. People who perceive that they are

514 CHAPTER 27  Hospice and End of Life distress (Figure 27-2). The MSAS-SF also enables patients to rate the extent to which particular symptoms being “called by others” or “going to the light” may try affect them, using a 5-point continuum between not at to get up even though no longer physically able.11 all (0) and very much (4). PAIN AND SYMPTOM MANAGEMENT The two most common forms of discomfort in 299 patients with advanced cancer completing the MSAS-SF Defining Pain at End of Life included pain (72%) and lack of energy (70%).56 Furthermore, more than 50% of these patients rated A painful death is among the greatest fears surrounding these symptoms as affecting them “quite a bit” or “very the end-of-life process; accordingly, one of the most much.” Finally, between 35% and 39% of these patients important goals in the management of terminally ill reported occasional psychological distress such as wor- persons is timely and effective pain management.16 rying, feeling irritable, and feeling sad. Clearly, the The hospice approach to pain supports this goal, specifi- physical and psychological effects of advanced cancer cally in terms of reducing the level of related distress to frequently affect most patients. a tolerable level within 48 hours of admission. The multidimensional element of pain, particularly at Although pain can be academically defined as “an end of life, was first recognized by Cicely Saunders, who unpleasant sensory experience associated with actual or defined pain as “not just an event, or a series of events, potential tissue damage,”54 the definition used in hospice but rather a situation in which the patient is held cap- is “whatever the patient says it is.”55 Thus, any patient tive.”57 Saunders defined the collective impact of these report of pain is acknowledged and addressed in a com- discomforting “events” as “Total Pain,” which is illus- passionate and efficacious manner. trated in Figure 27-3. In the hospice setting, pain assessment is considered In developing the interdisciplinary model of hospice the “fifth vital sign,”1 an important indication of the care, Saunders considered that each professional mem- patient’s physiological homeostasis and well-being. In ber had a role in helping ease the various contributions addition, pain is viewed as an impediment to the pa- to a patient’s total pain. For example, a hospice chaplain tient’s spiritual, psychological, and emotional processes could address spiritual pain, whereas a social worker of life review and meaningful closure with loved ones. might mitigate the issues of bureaucratic pain (i.e., the Hospice nurses are experts in the area of pharmacologic frustration of filling out the endless and tedious forms approaches to pain management. Working with the required for insurance claims). By addressing the many patient and family, they can quickly identify strategies to contributions to distress, patients’ energy resources can reduce, and in many cases eliminate, discomfort. Physi- then be marshaled for meaningful and comforting cal therapists can also provide the nonpharmacologic activities, thus enhancing their quality of life. In the con- interventions described in the previous section on com- text of total pain, Saunders’ approach to management fort measures, which may enhance the effectiveness of was to employ both pharmacologic and nonpharmaco- medications. In many cases, physical therapy interven- logic measures proactively rather than reactively. tions such as massage, guided breathing for relaxation, TENS, and gentle movement can even reduce the need Without a doubt, effective pain management is one of for pharmacologic agents. the most important of Saunders’ many contributions to the development of a standardized approach to compas- In cases where the patient is unresponsive, delirious, sionate end-of-life care. She was among the first to dem- or aphasic, potential causes of pain are identified and onstrate that inadequate pain management at the end of addressed. For example, an unresponsive patient with a life hastens death by increasing physiologic stress, myo- severe urinary tract infection would most likely be cardial oxygen demand, and the work of breathing.”57 treated for pain. In addition, if a patient has previously Furthermore, inadequate pain relief increases the burden reported a consistent pattern of pain during periods of of total pain, causing significant anguish for both the consciousness, it will probably be assumed that this patient and family. Accordingly, given the prevalence discomfort remains even when they are no longer able to and intensity of physical pain among terminally ill verify this. patients, Saunders advocated the use of opioid medica- tions in sufficient doses to maintain a consistent level of Prevalence of Pain at End of Life relief. Her well-known maxim in this regard was “con- stant pain needs constant control.”57 Nevertheless, Although the prevalence of pain at end of life will vary despite considerable evidence for their use, barriers exist depending on the nature of the terminal disease process, within society and the medical system that can prevent research indicates two thirds of patients with advanced adequate dosing of the highly effective opioid medica- cancer experience pain. Pain and discomfort are multidi- tions. Because of their potential for abuse and addiction mensional constructs. One assessment known as the as well as opioids’ popularity as street drugs, many states Memorial Symptom Assessment Scale-Short Form have restrictive laws that can limit their availability in (MSAS-SF)56 is a patient self-report of the spectrum both rural and inner-city pharmacies.1 Accordingly, it is of cancer-related sources of physical and psychological

Patient’s Name Date / / ID # MEMORIAL SYMPTOM ASSESSMENT SCALE – SHORT FORM [MSAS-SF] I. INSTRUCTIONS: Below is a list of symptoms. If you had the symptom DURING THE PAST WEEK, please check YES. If you did have the symptom, please check the box that tells us how much the symptom DISTRESSED or BOTHERED you. IF YES: How much did it DISTRESS or BOTHER you? Check all the symptoms you have Yes Not at A little Some- Quite Very had during the PAST WEEK. all bit what a bit much (√) (0) (1) (2) (3) (4) Difficulty concentrating Pain Lack of energy Cough Changes in skin Dry mouth Nausea Feeling drowsy Numbness/tingling in hands and feet Difficulty sleeping Feeling bloated Problems with urination Vomiting Shortness of breath Diarrhea Sweats Mouth sores Problems with sexual interest or activity Itching Lack of appetite Dizziness Difficulty swallowing Change in the way food tastes Weight loss Hair loss Constipation Swelling of arms or legs “I don’t look like myself” If you had any other symptoms during the PAST WEEK, please list them below, and indicate how much the symptom DISTRESSED or BOTHERED you. 1 2 II. Below are other commonly listed symptoms. Please indicate if you have had the symptom DURING THE PAST WEEK, and if so, how OFTEN it occurred. IF YES: How OFTEN did it occur? Check all the symptoms you have Yes Rarely Occasionally Frequently Almost had during the PAST WEEK. (√) (1) (2) (3) constantly Feeling sad (4) Worrying Feeling irritable Feeling nervous FIGURE 27-2  T​ he Memorial Symptom Assessment Scale-Short Form. (Chang VT, Hwang SS, Feuerman M, et al. The memorial sypmptom assessment scale-short form (MSAS-SF). Cancer 89: 1162-71, 2000. Copyright 2000, American Cancer Society. Reproduced with permission of Wiley-Liss, Inc., subsidiary of John Wiley and Sons, Inc.)

516 CHAPTER 27  Hospice and End of Life Disease effects BOX 27-4 Definitions of Terms Related to Addiction Treatment effects Addiction: a primary, neurobiological, social, and environmentally Fatigue based disease characterized by behaviors that include one or more of the following: impaired control over drug use, continued Anger at treatment failure Insomnia Family concerns use despite harm, and craving Fear of pain or death Dyspnea Loss of income Physical dependence: a normal state of adaptation manifested by a drug-class–specific withdrawal syndrome that can be provoked Helplessness Physical Loss of roles by abrupt cessation, rapid dose reduction, decreasing blood Depression Feeling isolated levels of the drug, or administration of an antagonist Anxiety Bureaucratic pain Tolerance: a state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more of the Psychological Total Pain Social drug’s effects over time Spiritual Pseudoaddiction: the false assumption of addiction in a person seeking relief from pain Why me? Why does God let me suffer? Pseudotolerance: the false assumption that the need for increasing doses of a medication is due to tolerance rather than What’s the point of it all? disease progression or other factors.61 Can I be forgiven for past wrongdoing? Breakthrough Pain.  I​n the presence of advanced dis- FIGURE 27-3  T​ he concept of Total Pain. (Adapted from Saunders ease (particularly with cancer), it is not uncommon for patients to experience brief intermittent episodes of C. Nature and management of terminal pain. In Shotter EF, editor: severe pain lasting from several seconds to several min- Matters of life and death. London, 1970, Dartman, Longman and utes. In most cases, this “breakthrough pain” occurs in Todd.) the presence of overall effective baseline analgesia. Although these episodes can occur without apparent critical for health professionals working in pain manage- provocation, they may also correlate with changes in ment to understand the true nature of addiction as well activity. Use of a pain diary such as the one illustrated in as physical dependence, tolerance, pseudotolerance, and Figure 27-4 can be helpful in identifying triggers (and pseudoaddiction, in order to avoid perpetuating existing premedicating accordingly, if needed). Breakthrough barriers to appropriate pain management at end of life. pain can be effectively managed, usually by providing a In reality, both past and recent studies have found addic- fast-acting medication in a specific percentage of the tion rates of anywhere between 0% and 7% in patients patient’s overall daily dose. receiving opioids for end-stage cancer pain.58,59 In end- of-life care, concern for patient comfort is first and fore- Pain Assessment most. Moreover, nurses and other health professionals working in a hospice setting may need to educate Decisions related to appropriate medications for and advocate for their patients in order to ensure their pain control are based on patient or caregiver reports. access to appropriate medications and need for optimal It is important for health professionals to recognize comfort. that patients, especially older ones, may be reluctant to report the true nature, extent, and severity of their In order to educate health professionals, the American pain. Barriers to accurate reports are numerous, Academy of Pain Medicine generated a consensus docu- including cultural differences, fear of being seen as ment in 2001 defining the terms addiction, physical complaining, lack of knowledge about pain control, dependency, and tolerance.60 These definitions are defined and fears of medication adverse effects, tolerance, or in Box 27-4. addiction.1 Types of Physical Pain It can be helpful for patients to maintain a pain di- ary, which allows them to record the impact of activi- In order to achieve the outcome of consistent analgesia, ties and other factors on their pain levels. Figure 27-4 it is important to understand the physiological sources illustrates an example of the American Cancer Society’s that contribute to pain. For example, physical pain can pain diary, which is also available on their website derive from organs, neural tissue, or musculoskeletal (www.cancer.org/docroot/MON/content/MON_1x_ components, each of which produces a distinct type of Pain_Control_Record.asp). The pain diary includes discomfort and requires a specific class of pharmacologic useful questions that can help physical therapists in the agents. An understanding of pain’s sources and behavior promotes the physical therapist’s effective advocacy and pain management. In general, nociceptive and neuropathic pain are the two major types of pain common at the end of life.

CHAPTER 27  Hospice and End of Life 517 Pain Diary for Date and Pain score Where pain is and What I was Name and Non-drug How long Other notes time (0-10) how it feels doing when amount of techniques the pain medicine lasted (ache, sharp, throbbing, it began I tried shooting, tingling, etc.) taken 0 1 2 3 4 5 6 7 8 9 10 No Moderate Worst pain pain pain you’ve ever had FIGURE 27-4  ​Pain diary. (Courtesy of the American Cancer Society.) assessment of pain such as location, nature (e.g., stab- can also be used to determine the appropriate medica- bing, throbbing, shooting), pain rating, and provoking tions in end-stage cancer (Figure 27-5). factors. Nonopioid Analgesics.  T​ his class of medications in- cludes acetaminophen and nonsteroidal anti-inflammatory Pharmacologic Measures for Pain Control drugs (NSAIDs). The WHO pain ladder recommends nonopioid analgesics for mild pain, which is less than 3 on There are several effective medications that can be used a 1 to 10 numerical scale where 0 is no pain and 10 is the for pain control in patients facing the end of life. This worst imaginable pain.16(p100) section will provide a brief overview of the three major classes of medications commonly used in a hospice set- Acetaminophen (Tylenol) is considered one of the saf- ting. These include nonopioid analgesics, opioid analge- est medications for long-term use in the management of sics, and adjuvant analgesics. mild pain and the reduction of fever.61 Its main mecha- nism of action is the inhibition of cyclooxygenase (COX), The selection of the appropriate class of medications an enzyme responsible for the production of prostaglan- is determined by the source of the pain as well as its dins. Acetaminophen is particularly effective for use in severity. The WHO has developed a pain ladder that nociceptive somatic pain of musculoskeletal origin. This

518 CHAPTER 27  Hospice and End of Life Fcraenecdeormpafrionm to decrease the risk of gastrointestinal bleeding, renal OpiosiϮdϮeavfnoedorrjnuemovpoapadnioietnidr,ate to dysfunction, and generalized bleeding that can occur Poar iinncpreerassisintigng 3 with the COX-type NSAIDs. Opioid for ϮϮmanilddojnutoovapmniootidderate 2 Opioid Analgesics.  O​ pioid analgesics are considered the most effective medications for the management of pain moderate to severe pain. Accordingly, the WHO pain ladder recommends these as the preferred medication in Poariinncpreerassisintigng such instances.61 ϮNaodnjoupviaonidt 1 Moderate pain is defined as between 4 and 6 on a 0 to 10 numerical scale, where 0 is no pain and 10 is the FIGURE 27-5  P​ ain level for patients with end-stage cancer. (Courtesy worst imaginable pain. Severe pain is defined as between 7 and 10 on the same numerical scale.16(p 100) These of the World Health Organization’s pain level for patients with end- medications bind to opioid receptors in the brain, block- stage cancer. http://www.who.int/cancer/palliative/painladder/en/) ing the release of neurotransmitters involved in process- ing pain perception. Thus, opioid medications are effec- drug can be used in isolation for mild pain and also has tive for all types of pain, and are also useful in treatment a potential coanalgesic effect when used with opioid of dyspnea. medications. Opioid medications can be derived from the resin of NSAIDs produce analgesia by reducing the biosyn- the opium poppy (codeine, morphine) or manufactured thesis of prostaglandins and thus preventing inflam- synthetically (fentanyl, methadone). Thus, there are nu- mation and reducing fever. Examples of common merous types of opioid medications available, such as NSAIDs include aspirin, ibuprofen, and naproxen. MS Contin, Oramorph, oxycodone, OxyContin, hydro- Like acetaminophen, these NSAIDs also inhibit the morphone, Vicodin, and Lortab. cyclooxygenase pathway. NSAIDs are also useful for mild nociceptive pain of musculoskeletal origin. Be- Morphine is considered the “gold standard” of the cause prostaglandins are found in high concentrations opioid analgesics and is used as a measure of dose in the periosteum, NSAIDs can be useful for mild bone equivalence. Dosing of opioid medications thus depends pain. The typical dosing of this medication is 500 to on the type of medication given as well as the route of 1000 mg every 4 to 6 hours for aspirin and 200 to administration. 400 mg at the same intervals for ibuprofen. The maxi- mum daily recommended dose for aspirin is 4000 mg, In end-of-life care, optimal pain control is the ulti- and that for ibuprofen is 2400 mg. These medications mate goal of pharmacologic treatment; thus, dosing is have a ceiling effect so that doses beyond the recom- determined by the level required to attain this outcome. mended maximum do not improve the analgesic ef- Fortunately, many of the opioid medications can be de- fect, but instead increase the risk of adverse effects.61 livered in either extended- or immediate-release formula- NSAIDs can produce gastric irritation through its tions, allowing for a more consistent level of control. inhibition of prostaglandins, which in turn decrease Often, both types of medications are used. the mucosal coating in the stomach. This reduction in mucosal coating can render the gut lining more vul- Opioid Adverse Effects.  F​ ortunately, allergic reac- nerable to injury from acids, pepsin, and bile salts, tions to opioid medications are extremely rare, and the thus increasing the risk of gastrointestinal bleeding. only contraindication to their use at end of life is a his- Kidney dysfunction can also occur as a result of inhi- tory of a hypersensitivity reaction such as rash or wheez- bition of renal vasoactive prostaglandins which ing. One of the more common opioid adverse effects is decrease blood flow to organ arterioles and reduce the constipation, and it is thus recommended that a prophy- glomerular filtration rate. This complication is more lactic bowel regimen be started immediately upon the likely to occur in the presence of dehydration.1 initiation of these medications. In addition to stimulant laxatives and the encouragement of adequate fluid A newer type of NSAID selectively blocks the cyclo- intake when possible, interventions such as abdominal oxygenase 2 (COX-2) enzymatic pathway and appears massage, range of motion, and upright mobility training can also assist bowel evacuation. Sedation is another common adverse effect of opioid use, particularly with the initial doses. This effect will often wear off after the first 24 to 48 hours. If improvement does not occur, stimulant medications may be added (the use of such medications is described in the following section on adjuvant medications). It is also important to recognize that although many patients may view sedation as a bar- rier to quality waking time with family and loved ones, others may consider it a welcome opportunity for rest, particularly if insomnia has been problematic.

CHAPTER 27  Hospice and End of Life 519 One of the most feared (yet relatively rare) complica- PALLIATIVE SEDATION tions of opioid use is respiratory suppression. Fortunately, this adverse event is usually preceded by sedation, which For some individuals, the end-of-life process may involve provides an opportunity for symptom reversal through the levels of pain that are intractable even with aggressive use of an opioid antagonist such as naloxone. Indications pain management efforts. In such cases, the only remain- for reversal generally include lack of arousability and a ing approach is to induce sedation in order to alleviate drop in oxygen saturation. The highest risk for respiratory conscious awareness of pain. Palliative sedation (PS) is depression occurs with the first doses of opioids in patients defined as “the monitored use of medications (sedatives, without a prior history of their use (opioid naïve). Opioid- barbiturates, neuroleptics, hypnotics, benzodiazepines tolerant patients who have achieved good pain control or anesthetic medication) to relieve refractory and unen- generally do not develop this complication. durable physical, spiritual, and/or psychosocial distress for patients with a terminal diagnosis, by inducing Nausea and vomiting can occur, particularly during varied degrees of unconsciousness.”62 the initial dosing of opioid medications. This adverse effect is thought to result from the combined effects of The American Academy of Hospice and Palliative delayed gastric emptying and vestibular sensitivity, Medicine describes mild and deep levels of PS, which which can also occur from these medications. Fortu- vary in terms of the level of consciousness preserved.63 nately, most patients habituate to this adverse effect in With mild sedation, smaller doses of short-acting medi- the first few days. Should this not occur, antinausea cations such as midazolam at an infusion rate of 0.5 mg/ medications can be added. hour are used, promoting enough alertness to allow the patient to engage in conversation. Should mild sedation Myoclonus can occur, particularly with high-dose not be sufficient, a deeper level may be required and in morphine therapy. This is thought to result from the this case, higher doses of midazolam may be used in accumulation of metabolites, especially in the presence addition to longer-acting medications such as benzodiaz- of renal dysfunction. This adverse effect can thus often epines and morphine sulfate.64 In having two progressive be eliminated with a morphine alternative. In addition, levels of PS available, patients and their families can diazepam may also be used. maintain a level of choice, which enables them to fully direct their care with the assistance of the hospice team. Pruritus (itching) is most commonly seen with the use of morphine, although it is sometimes seen with the use Ethical Framework for Palliative Sedation of other opioids. Antihistamines can be used to counter- act this adverse effect and are generally effective. The intent of palliative sedation is to provide comfort Adjuvant Analgesics.  ​This class of medications includes when all appropriate methods of pain control are inade- an array of agents that produce analgesic effects. These quate. Patients and families must clearly understand that include antidepressants, anticonvulsants, corticosteroids, the overall intent of PS is to provide relief from unendur- local anesthetics, and calcium channel blockers. Although able suffering, but not to hasten death. Nevertheless, the these medications can be effective for milder pain when end result for many patients undergoing PS will be used in isolation, they are most typically used in conjunc- the eventual cessation of respiration followed by death. tion with opioids. They can be particularly effective in the Although death is an expected outcome from the disease presence of severe neuropathic or bone pain. process itself, the addition of PS cannot be definitively Routes of Administration.  A​ nalgesic medications can excluded as a contributory factor. Thus, the ethical be administered through a variety of methods. Although framework in which PS is grounded is that of “double many patients with advanced disease are able to take effect,” which suggests that the beneficent intention of medications orally (either in pill or liquid form), others reducing suffering may produce the unintentional effect may require alternative forms of delivery. Thus, medica- of death. In addition, the principle of proportionality tions can be administered through a variety of routes, suggests that the selection of PS should be proportionate including mucosal, transdermal, rectal, or topical to the extent of patient suffering, treatment alternatives, approaches. One of the most common routes for pa- expected benefits, and possible harm.65 A 1997 ruling of tients without oral function is through rectal or vaginal the United States Supreme Court stated, “There is no suppositories. Medications can be also delivered through constitutional right to physician-assisted suicide. Termi- intravenous or intrathecal methods; however, whenever nal sedation is intended for symptom relief and is appro- possible, the least invasive approach is used. priate in the aggressive practice of palliative care.”64 Intramuscular injections are generally not used in Initiating Palliative Sedation end-of-life care as they are painful in themselves, and because rates of vascular drug absorption are highly The decision to initiate PS is based upon the assessment variable when using this approach. In selecting the pre- of patient symptoms and often, the patient’s stated desire ferred route of delivery for pain medications, the hospice to be free of his or her discomfort. Once it is clear that nurse will work closely with the patient and family to determine the most effective, consistent, and efficient approach.

520 CHAPTER 27  Hospice and End of Life An advance directive is a legal document that provides a clear statement of the patient’s desires for care in PS is the only remaining treatment option, the patient or the event of imminent death (a living will) and the health care surrogate (the individual appointed to make appointment of a person to make decisions on their be- medical decisions on the patient’s behalf) must be clearly half should they become incapacitated (medical power instructed in the goals and expected outcomes of treat- of attorney). A third element of an advance directive ment. Informed consent is typically required. Members includes an optional DNR document, which is usually of the hospice team are also available to provide any printed on bright orange paper and displayed in a prom- support that may be needed by the patient or family. inent place in the patient’s home and medical chart. Patients who elect hospice services do not need to have In most cases, PS is initiated at the onset of terminal a signed DNR in place. State-specific advance directives restlessness, an indication that death is imminent within can be downloaded through the National Hospice and days or hours. Although the most common indication Palliative Care Organization website (www.caringinfo. for PS is agitated delirium, others include pain, seizures, org/PlanningAhead/AdvanceDirectives/Stateaddown- and dyspnea and severe anxiety. Many patients have load.htm). Many patients who are in other settings such more than one symptom, which greatly compounds their as skilled nursing or acute care will have advance direc- distress. One patient of the authors described the feelings tives and a signed DNR in place. Physical therapists of terminal restlessness as “a horrible sense of doom and working with patients in these settings should know fear, like a weight crushing down on me.” whether or not they have a DNR in place. This informa- tion can be found in the medical chart. In most cases, a There are many different medications that can bright orange sign reading “DNR” will be placed on the be used for PS. They include central nervous system outside of the chart, where it can be easily noted. depressants such as midazolam, benzodiazepines, loraz- epam, and pentobarbital. Most of these medications are Confronting the Reality of Death administered intravenously. Another common formula- tion known as a hospice suppository contains metoclo- Being comfortable with dying is a challenge for many pramide to prevent gastrointestinal distress, diphenhy­ therapists and individuals because of the limited expo- dramine to dry up secretions, morphine sulfate (for sure during our training and clinical practice and the pain), lorazepam for anxiety, and haloperidol for delir- nature of modern culture. The process of understanding ium. These suppositories are inserted rectally every 3 to the meaning and nature of death, then being able to 8 hours as needed and are often a preferred method for speak of living and dying with comfort and ease, takes home use. time and practice through repeated exposure and experi- ence. This development can occur through reading, con- The frequency with which PS is used at end of life in versations with professional peers, and eventually during the hospice setting is estimated to between 20% and work with people approaching the end of life. This sec- 52%.66 A recent prospective cohort study performed on tion will introduce conversation topics that arise in a consecutive sample of 77 dying patients showed that clinical settings and promote adjustment to the dying 42 (54.5%) received PS. Interestingly, the patients who process. received PS had a significantly longer survival period than patients who were not sedated, a finding that has Decline, if not reversible, will lead to death. Fully been demonstrated in other studies as well.67 Patients in understanding the universality of death as more than an this study had a mean time to death of 22 hours, with a abstract concept can make us open to the possibility of range of 2 to 160 hours, with family members actively improvement, maintaining a functional level, or further involved in the decision to initiate PS. These families decline and death during the course of clinical care. perceived that it promoted a peaceful and comfortable Death is not failure by the patient or the therapist, but death. Similar time frames have also been reported in the natural course of life. The ability to give voice to this other studies.68,69 natural event as it occurs during the process of care can provide a sense of understanding that will support the When a patient is undergoing PS, family members coping of patients and family members. should be encouraged to talk to them and touch them. Gentle massage can be helpful in assisting the letting go Death is an experience fraught with an array of emo- process, and patients may respond with a change in tion. Patients often have limited experiences with death breathing that suggests relaxation. Sometimes, patients during their lifetimes and may find themselves struggling may respond in other poignant and life-changing ways. with unfamiliar circumstances and feelings as their con- ditions progress. How health professionals address the ADVANCE DIRECTIVES: PLANNING events that occur at the end of life can offer support and AHEAD FOR DEATH WITH DIGNITY understanding to allow the completion of this process with less distress and better understanding. Patients and As this chapter has suggested, a person facing end of life family members have identified geriatric and oncologic has many options for care and comfort. A major source of family stress often revolves around attempts to deter- mine what a family member would want when the patient has not identified or disclosed his or her choices.

CHAPTER 27  Hospice and End of Life 521 medical care that includes physical and intentional pres- feel that way” (why not?). In order to provide compas- ence, developing an understanding of their individual- sionate care by being present to the dying individual, ized experience, and maintaining the patient’s humanity health professionals must face their own fears of loss, and dignity as essential to their spiritual well-being.70 suffering, and death. To be effective, physical therapists need to recognize their own as well as the aging adult’s Reframing Physical Loss and Dying feelings, have a sense of their strengths and weaknesses, and be aware of their thoughts and feelings about death Loss and suffering are a natural, albeit unpleasant, part and dying, as these may all have an impact on how care of the dying process. Often there is a component of sig- is provided. Awareness that any discomfort the therapist nificant physical loss such as the inability to walk, stand, feels is a personal reaction and may not be shared by the or even get out of bed during this experience. The phys- older adult who is at the end of life can help the therapist ical therapist can use clinical observations made during with appreciating the continuity of life. initial examination or ongoing assessments to affirm the person’s maximal efforts at mobility and function in Unfinished Business light of a progressive or deteriorating condition. Under- standing these losses can change the aspects of suffering Often, the older patient may be comfortable with death, that are then experienced and one can discover a mean- even anticipating it as a means of meeting a spouse or ing to life by the attitude taken toward this unavoidable other loved one who predeceased him or her. However, suffering.71 the patient’s family may still be resisting the finality of death and may express discomfort as wanting more Spiritual Awareness therapy, pushing the patient to do more, to not give up, etc. This lack of acceptance of the loved one’s death may In the past century, perhaps because of the advances of be a result of unfinished business. Clinically this can be medicine, emphasis has been on the physical changes addressed through using the various practice patterns that occur as the body deteriorates in the process of dy- identified earlier in this chapter to sustain a sense of ing rather than on the spiritual changes with dying, as in hope rather than the abandonment that may be felt from past centuries. Previously, societies have examined death a discharge from having “failed” therapy. The personal as a spiritual event and created treatises such as the issues of unfinished business can be addressed as well. Christian Ars Moriendi or “Art of Dying”72 and the Buddhist Tibetan Book of the Dead.73 Evidence of spiri- Unfinished business has been identified by Elizabeth tual well-being is found to improve coping with terminal Kubler Ross79 and others80 as tasks and relationships illness.74 It is important that members of the IDT meet that need completion or resolution before the end of life, the spiritual needs of patients and families receiving or to get through any difficult situation. Byock81 has hospice care, even if their spiritual/religious tradition or outlined four communication tasks of the dying and beliefs differ from one’s own.75 their families: “Please forgive me,” “I forgive you,” “Thank you,” and “I love you.” Offering these words of Dealing with Death and Dying goodbye may help families find closure. Being in the presence of those close to the end of life and struggling In physical therapy practice of aging adults, it is com- with their own issues of pending loss will in many cases mon to provide care to individuals who are facing death bring to the level of awareness of the family and/or prac- either imminently or in the not so distant future. Many titioner feelings and emotions related to their own past physical therapists’ first experience of death is with an or anticipated life losses. older patient with whom they have grown close through the therapeutic relationship. When confronted with the Being able to process and resolve one’s own personal inevitability of the patient’s death, a physical therapist issues of unfinished business is a healthy and life-affirming may feel anxiety or feel incapable of coping with such a process that is recognized as anticipatory grief for patients situation.76 A common and natural emotional reaction is and families. Patients can be teachers to therapists as well. fear that can be perceived by the patient from the thera- Those at the end of life may report increased comfort and pist’s body language and facial expression as pity.77 The peace as this occurs. They may report a clarity and mean- therapist’s recognition that death is inevitable and natu- ing in life that was not evident previously. For the health rally occurring can bring about a freedom from the fear and well-being of physical therapists as end-of-life care- and a recognition that everyone has choices in how one’s givers, reflection around such issues can promote more days can be lived. Listening to the patient with empathy effective listening ability and long-term work satisfaction. and unconditional positive regard is a way of communi- Most hospice workers have a spiritual belief system, cating compassion77,78 without using nonsensical state- which may not be connected to an organized religion or ments such as “I know how you feel” (you don’t) or be well defined, but consist of some belief in something “It will be alright” (it may not) or worse, “You shouldn’t beyond the self, some way of making meaning of the world and life.82 Patients and families can be guided to access their own religious or spiritual support system, or

522 CHAPTER 27  Hospice and End of Life of one’s own feelings and issues with loss, grief, and death is necessary to maintain personal health while pro- that of the hospice program, to cope with the realities and viding the best intervention and support to individuals as unknown of death. they die. SUMMARY REFERENCES End-of-life care is a challenge for both the new and expe- To enhance this text and add value for the reader, all rienced physical therapist. Clinical expertise is developed references are included on the companion Evolve site through an ongoing practice of reflection and mindful- that accompanies this text book. The reader can view the ness.83 Knowledge of aging and disease processes, pain reference source and access it online whenever possible. and symptom management, and the different patterns of There are a total of 83 cited references and other general care used to support a palliative care approach is essen- references for this chapter. tial. Understanding the physical therapy role within the hospice interdisciplinary team approach is important for successful practice integration. Personal exploration

28C H A P T E R The Senior Athlete Barbara J. Hoogenboom, PT, EdD, SCS, ATC, Michael Voight, PT, SCS, OCS, ATC, CSCS INTRODUCTION as the physically elite elderly2 and are “a testament to the remarkable resilience of the human body when it is As the population of the United States ages, more indi- kept properly maintained.”2(p288) They combine good viduals are living longer and staying physically active into inheritance (genetics)3,4 and luck while maximizing their old age. As the baby boom generation enters the over-65 potential and longevity by successful training and good age category during the years 2010 to 2030, the increase health habits. Those who participate in athletics into in the population of healthy older-age individuals will be older age offer an amazing view of successful aging and dramatic, and the number of older-aged athletes is ex- provide a model for how adults can defy the physical pected to increase concurrently.1 This athletic subgroup effects of aging and maintain outstanding physical abili- of aging adults represents a truly unique example of those ties and a high quality of life well into the eighth and who are aging exceptionally well (Figure 28-1). Athletic ninth decades of life (Figure 28-2). Certainly, the endeavors in this unique aging population range from demand for sports rehabilitation services for these aging weekend or fitness activities to competitive athletics and athletes will increase as they age and continue their the Senior Olympics. Although many senior athletes are unique activity levels. examples of successful aging and continue to be active, vigorous, and competitive, the reality is that the senior The physical therapist who expects to treat the older athlete is slower and weaker than in his or her youth. The athlete must have experience and a good working knowl- reasons for the inevitable declines in athletic performance edge of aging and the mechanisms of athletic injuries. The are important to understand. Some senior athletes have ideal individual would have firsthand experience with car- been active for a lifetime; others began their fitness and ing for athletes before, during, and after athletic participa- competition during the fitness craze of the 1970s and tion and know both the physical and psychological de- 1980s, coming to athletics later in life. Masters and age- mands sports place on the participant. This clinician group distance running, cycling, and swimming records should be versed in a diversity of areas, including anat- are broken at a staggering rate. The Masters’ marathon omy, cardiovascular and muscle physiology, nutrition, record was shattered at the Boston Marathon in 1990 biomechanics and kinesiology, physical training, flexibil- when John Campbell (as a newly minted 40-year-old) ity and conditioning programs, protective/preventive tap- finished among the top five runners of all age groups, in ing and/or bracing, and rehabilitation. Understanding 2:11:04. The fastest senior marathon time is held by then age-related physiological changes and their ramifications 80-year-old Helen Klein, who in 2002 ran the California relating to physical exercise and rehabilitation is vital to International Marathon in 4:31.32. She has run an amaz- the patient’s safe and successful functional return to par- ing 59 marathons and 136 ultramarathons! In 1991, at ticipation and, in some cases, competition. Knowledge of age 83, Johnny Kelley ran his 60th Boston Marathon. pathologic changes, comorbidities, and their effects on the Jenny Wood Allen of Scotland completed the 2002 ability to participate in athletic activities is critical in the London Marathon at age 89 years, making her the oldest design and implementation of a rehabilitation program woman ever to finish a marathon.2 Although there is for the older athlete. inevitable decline in performance levels with age, the physical limits of the human body are constantly be- This chapter defines the senior athlete and describes ing challenged by senior athletes of all sports and walks typical systems changes and characteristics found in these of life. individuals. Musculoskeletal problems and injuries com- mon to the senior athlete are discussed and presented. This chapter will focus on those individuals who The role of comorbidity also is considered. A unique as- physically challenge themselves by participating at high sessment is presented with pertinent examples for use levels in competitive or recreational sports throughout with the senior athlete. Practical considerations for reha- their adulthood. These individuals have been referred to bilitation, equipment recommendations, and return to Copyright © 2012, 2000, 1993 by Mosby, Inc., an affiliate of Elsevier Inc. 523

524 CHAPTER 28  The Senior Athlete terms “masters athlete,” “geriatric athlete,” “aging athlete,” and “senior athlete” are not synonymous. FIGURE 28-1  8​ 7-year-old yoga practitioner, group leader. Masters athletes may not be senior athletes. Masters athletes are competitors in a given sport who exceed a FIGURE 28-2  Y​ oga group at senior retirement center, led by minimum age criteria, which are often in the 20s, 30s, and 40s. For example, in competitive swimming in the 87-year-old leader. United States and Canada, the minimum master’s age is 18 years (Table 28-1).5 The average nonathletic but well athletics are considered. Finally, case studies are used to older adult is not discussed in this chapter, nor is the care illustrate the interrelationship among the variables that of former athletes reviewed unless those athletes are still affect treatment of the senior athlete. actively engaged in regular physical activity. For the pur- pose of this chapter, there are three groups that comprise DEFINING THE POPULATION: the population described as the senior athlete. Although WHO IS THE SENIOR ATHLETE? there may be an overlap, these groups have some appar- ent differences that influence their need for rehabilitation The physically elite older adult represents a small per- services. Each group is dealt with in turn. Table 28-2 centage of the young-old (65-74 years), old (75-84 years) provides both a Centers for Disease Control and Preven- and old-old (85-99 years),2 many of whom are able to tion (CDC)–related definition6 and a description of the outperform individuals years younger. There is often level of activity for the wide variety of athletes that may confusion about the definition of a senior athlete. The be considered “senior athletes.” The first group consists of former competitive athletes who have continued to exercise recreationally, for example, the football or field hockey team player who is now conditioning on a more individual basis, using an activity such as running, swimming, or cycling. Many of these individuals may have sustained a significant injury during their earlier competitive play and therefore may not currently participate in competitions or tournaments; rather, they have adopted independent or group fitness as a part of their way of life. The older recreational athlete encompasses lifelong athletes who trained intensively for a period in their lives and currently may or may not be training at a relative intensity that is comparable with their earlier training levels. The physical performances of these noncompetitive athletes are hard to describe and quantify. This group utilizes a wide variety of sports and training intensities; however, these athletes share the dedication to fitness, healthy living, and regular activity that support this categorization. Virtually all the athletes who played team sports as competitive performers and who are still exercising are training at some other sport or activity, often at the recreational level. The second group is composed of lifelong athletes. Again, these athletes are involved in a spectrum of activities and training intensities, making their participa- tion rates and physical performances hard to describe and quantify. Most are lifetime “sports people,” some of whom are recreationally active and others who compete (Figure 28-3). They play tennis or golf; they run, cycle, or compete in triathlons. They may even participate in several different activities, but their involvement has been primarily in one sport or group of sports, some at the local level and others at the national or elite level. The definition of a competitive senior athlete for the purposes of this chapter is “one who participates in an organized team or individual sport that requires regular competition against others, places a high premium on

CHAPTER 28  The Senior Athlete 525 TA B L E 2 8 - 1 Masters/Seniors Sport Organizations and Competitions Sport Organization Ages Age Divisions Events World and National 35-1001 5-y increments All stadia (in stadium) and Masters Athletics Age 351 5-y increments nonstadia track and field events Masters Running 501 No age divisions Road races Senior Golf 18-1001 5-y increments Designated Senior Golf (USGA) 30 and up 5-y increments tournaments Masters Swimming Designated Masters swimming (USMS) events Worldwide Senior Designated Senior Tennis events Tennis Circuit (USTA) (Data from www.world-masters-athletics.org, www.seniorjournal.com, www.usga.com, www.usms.org, and www.itftennis.com.) TABLE 28-2 Descriptions of Types of Senior Athletes, Using CDC Guidelines Descriptors Level and Sedentary Recreational Competitive Elite intensity of , CDC recommendation CDC recommendation for CDC recommendation for . CDC recommendation exercise for substantial health substantial health greater health benefits: for greater health benefits benefits: benefits, PLUS specific Typical 300 min/wk of moderate- and varied intensities activities ADLs and low-level 150 min/wk of moderate- intensity* aerobic activity of training for functional tasks only intensity* aerobic or 150 min/wk of high-level competitions activity or 75 min/wk vigorous-intensity* in select sports of vigorous-intensity* aerobic activity, PLUS aerobic activity PLUS muscle strengthening Registered “senior” or muscle strengthening 2 2 or more days/wk “masters” athletes or more days/week who train and compete Runners, cyclists, tennis nationally and Home or health club, players, and golfers who internationally individual or group compete in small, local exercisers, without events competitive participation *Moderate intensity is equivalent to brisk walking; vigorous intensity is equivalent to jogging or running (www.cdc.gov). FIGURE 28-3  ​Women’s senior tennis team, Riverwoods Plantation, excellence and achievement, and requires systematic training.”7A significant subgroup of athletes in this rec- Estero, FL. reational group are the aging athletes who are consid- ered physically elite. They train and compete at high levels, regionally, nationally, and internationally in events such as the National Senior Games or the World- wide Senior Tennis Circuit. This population may have a disproportionate amount of the overuse type of injury. For these individuals, athletic activity is as much a part of their routine as dressing or eating meals. They are reluctant to stop participating in their chosen activity, even in the face of significant pain or dysfunction. The final group is made up of the nonathlete who began to exercise late in life (arbitrarily, after age 40 years). This is a small but significant group who may be recreationally or competitively active. These individu- als present a unique set of problems related directly to beginning physical activity at an older age and indirectly

526 CHAPTER 28  The Senior Athlete Mean disability scoreAGING AND PHYSICAL CHANGES SPECIFIC TO THE SENIOR ATHLETE to their reasons for beginning to exercise. In many instances, exercise has been initiated by a health crisis. All senior athletes, regardless of the category in which Common examples of this type of individual may in- they fall or the activities they perform, experience some clude the patient who has experienced coronary symp- predictable age-related changes. Senior athletes are gen- toms (or may be a prime candidate for them) that is the erally less flexible8,11,12 and have lower muscle masses,4 direct result of a number of controllable risk factors in- lower aerobic capacities,1,4 and less well tuned thermo- cluding improper diet (obesity) and lack of exercise. In regulatory mechanisms13 than they did at a younger many cases, the physician has prescribed a progressive age. They are likely to have osteoarthritis of the weight- walking program as a beginning or introduction to exer- bearing joints, although not necessarily brought on by cise and positive health behaviors. The fact that a per- their previous level of physical activity or exercise.14,15 In son’s walking program was begun as a result of a heart fact, it has been demonstrated that older, recreational attack does not protect him or her from musculoskeletal athletes do not sustain joint changes related to their injury, but an injury or previous dysfunction may inter- activity or intensity.16 Age-related changes affect train- fere with motivation for recovery from the cardiac event. ing, injury, treatment, and recovery of the older athlete and must be considered when designing their rehabilita- Opportunities and Organizations tion program. It is well known that vigorous exercise for Senior Athletes throughout middle and older ages is associated with reduced disability and increased longevity.17 For exam- The three groups of senior athletes may differ in the ple, runners who were running 60 minutes/week with a quality, frequency, and intensity of their exercise. Many mean age of 78 years had strikingly lower disability older athletes are involved in racquet sports, running, rates, especially women, and had prolonged survival in a triathlon, walking, and low-impact sports such as golf 21-year longitudinal study. Clearly, lifelong athleticism and bowling. Each of these sports can be played in a has the potential to slow the functional consequences of highly competitive manner against an opponent, a aging (Figure 28-4).1,17-21 score, or time.8 Competitive senior athletes can be found in any of the three categories of athlete previ- Musculoskeletal ously described. Competitive amateur Masters Events have been established for years and are sponsored by It is well accepted that continued or progressive exercise more than 50 countries, for example, swimming,5 and training affect an aging musculoskeletal system in weight lifting, running,9 and cycling.9 Each of these many ways.22-24 Similar to the younger athlete, the older sporting events encourages participation of the aging athlete incurs acute or traumatic injury (macrotrauma) athlete by offering a wide variety of age categories. as well as overuse injury (microtrauma).8 Unlike the As an example, the United States Masters Swimming younger athlete, however, these injuries are superim- Organization boasts more than 50,000 members in posed on an aging musculoskeletal system and recovery more than 450 local clubs located throughout the may take longer. Therefore, prevention takes on a more United States.5 Professionally, the “senior” golf tour10 important role in this population. Proper equipment and Masters Races for runners are the most high- selection and use, for example, shoes, racquet, and profile events. The increase in the number of aging stretching and training techniques must be encouraged active adults implies that the number of events and to prevent problems and will be discussed in a subse- competitors will continue to grow. quent section. The National Senior Olympics formed in 1987, and 0.6 Female controls (n=69) now known as the National Senior Games (after its 0.5 Female runners (n=54) name change in 1990), provides multisport competitions 0.4 Male controls (n=87) every odd year for adults aged 50 and older.2,9 The 0.3 Male runners (n=230) events include archery, badminton, basketball, bowling, cycling, golf, hockey, horseshoes, race walking, racquet- 0.2 ball, road races, shuffleboard, softball, swimming, table tennis, tennis, track and field, triathlon, and volleyball. 0.1 There are both summer and winter National Senior Games, with the summer games being the most popular, 0 drawing more than 12,000 participant athletes from 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 more than 90,000 seniors who attempted to qualify in 2007.9 The winter games are much smaller, drawing less Year than 500 participants for five winter sports. These com- peting senior athletes “raise both physical and psycho- FIGURE 28-4  ​Disability rates in male, female, and nonrunners. logical ceilings and shatter the barriers of expectations that society has for the aged.”2(p290) (Data from Chakravarty EF, Hubert HB, Lingala VB, Fires JF: Reduced disability and mortality among aging runners: a 21-year longitudinal study. Arch Intern Med 168(15):1638-1646, 2008.)

CHAPTER 28  The Senior Athlete 527 Changes common to the aging joint include deteriora- FIGURE 28-5  ​Senior weight lifter. tion of joint surfaces, breakdown of collagen fibers, and a decrease in the viscosity of synovial fluid, which can result diminish age-related atrophy, and prevent specific inju- in loss of flexibility and an increase in joint stiffness. ries.27 Most senior athletes incorporate a component of Osteoarthritis is a common manifestation of these changes PRT in their workouts in order to slow the loss of lean and will be discussed in a later section of this chapter. body mass. Although a decrease in bone mineral density (BMD) is common with advancing age, the senior athlete perform- Cardiopulmonary ing higher levels of vigorous weight bearing exercise and resistance training (as promoted by the CDC6) may expe- Longitudinal studies of the wide variety of markers of rience less bone density loss. In fact, the results of a 5-year longitudinal study of male master runners aged 40 to cardiovascular fitness show a predictable decline with 80 years demonstrated maintenance of BMD despite moderate decreases in training volumes as the runners increasing age. Physiological functional capacity (PFC) aged. These runners demonstrated a slower decline from peak bone mass, indicative of bone maintenance, not has been studied extensively in runners and swimmers by loss.25 However, master cyclists and swimmers who per- formed little weight-bearing activity showed less bone Tanaka and Seals,19,21 who found only modest declines density than age-matched controls.26 until age 60 to 70 years, with an exponential decrease Changes affecting the muscular system include a decrease in the size, number, and type of muscle fibers. thereafter. Age-associated declines in physiological deter- The loss of muscle occurs at a rate of 1% to 3% annu- ally and fat increases at about the same rate, 1% per minants of performance may occur at different rates in year. Muscles experience a decrease in respiratory capac- ity and an increase in fat and connective tissues. These men and women, especially in short-distance events as changes affect the gross appearance of an older athlete. Individual motor units lose fibers, which result in a compared to long-distance events. Physically active indi- decrease in the force-generating ability of that muscle. There is an effective loss of type II fibers, which results viduals, however, demonstrate less of a decline than in a higher percentage of type I fibers.2,27 Although this change in percentage may increase the muscle’s ability to sedentary individuals (Figure 28-6).2,3,30 In fact, if body sustain performance during endurance activities, it may limit the muscle’s ability to generate strength and power. dcoemclipnoessitiinonV· Oan2dmpaxhycsiacnalbaecdtievcitryeasaerde kept constant, Thus, as muscle fibers are replaced with fat and connec- from 10% per tive tissue, muscle fibers are lost, especially type II fibers, the muscle’s ability to forcefully contract is diminished, decade to 5% per decade.4,31 Although the PFC declines accounting for the general loss of force production seen with aging. Women are more vulnerable to loss of func- with advancing age are somewhat predictable, the rate tion secondary to type IIa muscular atrophy,27 and women appear to experience greater declines in muscu- of decrease in maximal aerobic capacity is determined lar strength and power (particularly in the upper ex- tremities) than men.21 Muscular strength as defined by largely by the corresponding reduction in exercise stimu- Olympic weight lifting capacity declines linearly at the rate of 1% to 3% annually until the seventh decade, and lus. Simply stated, those who undergo the largest de- then accelerates significantly.28 The rate of strength decline is directly related to the specific activity of the crease in exercise volume or intensity will also demon- individual. For example, weight lifters experience less strength decline (0.5%/annually), whereas runners expe- straTtheethme alaxrimgeustmdepcerrecaesnetaingePFoCf .V2·1 O2 max that can be rience a slower decline of endurance (Figure 28-5).29 used during exercise increases up to 90% in elite endur- The positive changes that occur in muscle as a result ance athletes as compared to sedentary controls. Results of resistance training in the older athlete of both genders should encourage strength training as an important of a study of elite mountain runners demonstrated the countermeasure against the sarcopenia of aging.4,11,18,23,27 Progressive resistance training (PRT) is an important maintenance of a 3.5-fold greater endurance capacity as part of an overall fitness program for senior athletes. PRT has been successfully implemented in the aging measured by oxygen uptake at the anaerobic threshold population in order to increase strength, muscle size,

528 CHAPTER 28  The Senior Athlete 6 Trained (r ϭ Ϫ.767) 80 Trained (r ϭ Ϫ.766) Sedentary (r ϭ Ϫ.523) 70 Sedentary (r ϭ Ϫ.420) 5 y ϭ Ϫ0.70x ϩ 91.0 60 4VO2max (liters • min-1)y ϭ Ϫ0.059x ϩ 6.74 50 VO2max (ml • kg-1• min-1) 3 40 y ϭ Ϫ0.24x ϩ 51.7 30 •2 y ϭ Ϫ0.037x ϩ 4.75 • 20 1 10 0 0 40 50 60 70 40 50 60 70 Age (yr) Age (yr) FIGURE 28-6  E​ ffects of age on V· o2max in trained and sedentary men. Note that even though both trained and sedentary subjects show predictiable age related declines, trained subjects generally performed better than sedentary subjects at all ages. (Adapted from Suominen HE, et al: Effects of “lifelong” physical training on functional aging in men. Scand J Soc Med 14(suppl):225-240, 1977.) . fact, the limits of functional performance in the older (Vo2 at) up to the age of 701 years when compared athlete are largely unknown. Maintaining excellent car- with untrained peers. Maintaining a higher endurance diopulmonary endurance capacity at the age of 70 years capacity into the seventh decade of life is a sign of ex- is a sign of extremely successful aging, and senior ath- tremely successful aging, which positively affects quality letes who do so have achieved superior fitness by lifelong of life, functional ability, and longevity (Figure 28-7).3 participation in physical activity. Such participation, when combined with favorable genetics produces a high The loss of heart rate variability (HRV), frequently quality of life and enhanced longevity.3 seen in sedentary aging adults, is associated with increased mortality and prevalence of cardiac events. Injuries and Physical Changes When runners older than age 60 years with a 40-year history of endurance training were studied and com- Currently, there is a lack of consensus on whether older pared with sedentary matched controls, researchers athletes experience different rates or types of injury, when found that the age-related decline in HRV was mediated compared with younger athletes.11 Matheson et al8 studied by lifestyle. For example, long-term participation in the distribution of injuries between older and younger in- endurance training produced an increase in HRV and dividuals and found a greater incidence of meniscal injury, exercise work capacity, which are established predictors degenerative joint disease, and various inflammatory con- of enhanced cardiovascular function and positively ditions along with a lower incidence of patellofemoral affect longevity.32 Conventional wisdom about aerobic pain and stress fracture in older athletes.8 In a study of fitness, performance limits, and age-related decline is challenged by the performances of senior athletes. In Aging ↓ Training intensity and volume FIGURE 28-7  M​ ultisystem effects of the typical response to aging ↓ Maximal ↓ Maximal ↓ Maximal heart rate stroke volume a-v O2 difference through training, endurance is maintained, partially decreasing nega- ↔ Exercise ↓ Maximal oxygen tive effects of age.  (From Tanaka H, Seals DR. Endurance exercise economy consumption ↓↔ Lactate performance in Masters athletes: age-associated changes and under- threshold lying physiologic mechanisms. J Physiol 586:55-63, 2008.) ↓ Endurance exercise performance

CHAPTER 28  The Senior Athlete 529 masters athletes involved in track and field, Kettanen with these types of injuries. For many reasons, older et al33 reported that about half were injured in the course athletes may actually be more prone to overuse injuries of a year, and a third of those who were injured had to be than younger athletes (Figure 28-8).36,37 First, older ath- out of training for a month or longer. Another study of letes have stiffer collagenous tissues and are less flexible 70- to 81-year-old athletes who participated in a variety of than younger athletes.30,36,38 Second, most have at least sports found that 81% sustained at least one sport-related some arthritic changes in weight-bearing joints that can injury, 38% of which were related to overuse.34 Injuries lead to altered movement strategies secondary to pain.18 sustained by the older athlete can be described as macro- Third, muscle mass is reduced, offering less shock ab- and microtrauma by the mechanism of injury. Although sorption and protection against external forces.4,23,39 the injuries may be similar to younger athletes, unique features exist, which will be discussed next. Muscle soreness, a common symptom experienced by Acute, Traumatic Injury (Macrotrauma).  ​Acute mus- many active older adults, is attributed to microscopic culoskeletal trauma is different in the older athlete than injury to muscle and connective tissue. Generalized in the younger athlete. Because many older athletes muscle soreness is often noted by senior athletes at the participate less in collision sports, major contusions, beginning of an exercise program or when new types of fractures, and multiple ligament trauma occur less fre- exercise are added to an existing program, and is consid- quently. The exception to this is in sports such as cycling, ered normal or a necessary prerequisite to strengthening. hiking, climbing, and skiing, where falls and accidents Delayed-onset muscle soreness (DOMS) is similar in the do occur as a potential consequence of participation. aging population as in younger populations and typi- Because of the loss of density in aging bone and the cally occurs 24 to 48 hours after exercise. Eccentric increased stiffness of ligamentous tissues, the senior ath- exercise appears to pose the biggest risk for development lete is more likely to sustain a fracture than to rupture a of DOMS.23,40 Prolonged muscle soreness (significant ligament in a macrotraumatic event. Likewise, because pain that lasts longer than 48 hours after exercise) of increased collagenous stiffness, senior athletes are should be evaluated as it could indicate muscle or tendon more likely to tear or avulse a muscle than sustain a injury that may be the result of overtraining either by muscular strain during athletic participation. For the frequency, duration, or intensity. In fact, cross-training purposes of this chapter, traumatic injuries will be may be more effective to avoid orthopedic stress than operationally defined as those injuries resulting from a low-intensity training between heavier training sessions. single traumatic event, which often involves uncon- trolled force or momentum. When macrotraumatic inju- Joint pain and associated effusion are common in the ries such as fractures, dislocations, ligamentous sprains, active aging population. Pain with specific movements or and muscle strains or tears occur, they can be devastating pain that occurs after certain activities that is not “joint to the senior athlete because of the length of time it takes pain” or DOMS can occur and are more like the “over- to recover. use” injuries that occur in younger athletes. Joint-related Detraining or deconditioning occurs as a result of FIGURE 28-8  U​ se of supportive knee brace by senior athlete for lack of exercise and occurs more rapidly than the time it takes to achieve conditioning for persons of all ages. The tennis. rate of detraining may occur faster with aging as a result of the insidious decline that occurs in all systems.3,33,35 The aging muscle, with less mass and fewer sarcomeres, may show rapid atrophy and further loss of muscle mass after injury and the requisite immobilization or healing time frame. The period of rest required after joint or muscle injury can mean the end of athletic activity for an older athlete because of this detraining effect. Overuse Injury (Microtrauma).  ​Most competitive ath- letes suffer from injuries that fall into the overuse cate- gory and older athletes are no exception. For the pur- poses of this chapter, overuse injuries or microtraumatic injuries will be operationally defined as those injuries resulting from training but not attributable to a single traumatic event. Many microtraumatic injuries related to sport participation or training for sport occur in or around the musculotendinous unit. These injuries in- clude muscle strains, bursitis, and a wide variety of ten- dinopathy. In-depth discussion of varied presentations and differentiation of tendon pathology is beyond the scope of this chapter, but many senior athletes present

530 CHAPTER 28  The Senior Athlete system to protect and offload the aging, potentially arthritic weight-bearing joints of the senior athlete.35 pain usually can be attributed to a specific set of circum- Treatment of the senior athlete with osteoarthritis of the stances, change in routine or volume of activity, or to lower extremities should focus on progressive resistive structural abnormalities. For example, the older athlete exercise and patient education regarding functional ac- with medial knee pain may in fact have tendinitis of the tivities, with emphasis on activities that minimize com- pes anserine region. Other examples may include pain in pression and shear (so-called joint-sparing techniques) to the subacromial region as a result of impingement of the avoid a progression of impairments. Exercise modifica- suprahumeral space, or plantar fasciitis, which may indi- tions, when necessary, should focus on those activities cate a need for orthotic fabrication. Structural abnor- that minimize weight bearing and joint compressive malities may be a consequence of age, such as in the os- loading, for example, stationary cycling, rowing, swim- teophyte found in aging shoulders; postural changes or ming, and walking instead of running2,15,16,36,48 or the muscular weaknesses; or structural abnormalities, which athlete should be counseled to vary types of training may be chronic such as in the individual who has always between those that offer greater and lesser joint forces. had knee varus. It is important to note that anatomic pathology is not always correlated with dysfunction and Degenerative arthritis of the hip is quite common in impairments of activities of daily living (ADLs). Several the aging athlete because it is one of the most commonly authors have found that rotator cuff tears (RCTs), acro- affected weight-bearing joints. Groin pain, hip muscle mioclavicular osteoarthritis, and subacromial spurring weakness, and subtle losses of range of motion are the occur independent of normal function, and in fact 54% primary symptoms of hip dysfunction and may be of individuals older than age 60 years had magnetic reso- indicative of progressive hip degeneration, including nance imaging (MRI)–confirmed RCTs, 75% had acro- labral lesions49 and other mechanical pathologies. Ath- mioclavicular (AC) arthritis, and 33% had subacromial letes with symptomatic degenerative arthritis of the hip spurring but were clinically and functionally asymptom- must limit or avoid weight-bearing athletic activities in atic.41,42 Pain near a joint in the aging athlete should not order to avoid progression of the articular break- be automatically interpreted as osteoarthritis or another down.15,36,47 Continued progression of the degenerative microtraumatic source but rather should be carefully and joint disease, however, often results in the need for hip systematically evaluated using both a clinical exam and arthroplasty. Baby boomers will drive an increase in movement-based exam, with the goal of identifying ana- demand for total joint arthroplasty, while concurrently tomic abnormalities and their effect on function. expecting return to athletic activity as an outcome of the Osteoarthritis and Joint Arthroplasty.  A​ rticular de- joint arthroplasty.50 Many senior athletes, of all levels of generation, commonly known as osteoarthritis (OA), participation, undergo total joint arthroplasty in order is the most common joint pathology of aging and occurs to continue participation in their sport. As a result, total over time. Characterized by joint space narrowing, os- hip arthroplasty is being performed in younger (younger teophytes, swelling, morning pain and stiffness, and than age 50 years), more active individuals, and the eventually joint deformity, articular degeneration can be longevity of the prosthesis itself is increasing.50 accompanied by muscle weakness. Weight-bearing joints are most prone to OA.16,43 The prevalence of osteoar- Like OA of the hip, OA of the knee may progress to thritis in the hip and knee is high, even in older ath- such an extent that the senior athlete chooses a total letes.44-46 However, primary osteoarthritis of the hip was knee arthroplasty (TKA) as a strategy for pain relief and found in only 4% of former runners as compared to improvement of function. As the outcomes of total knee 8.7% of nonrunning controls,47 indicating that running replacement have improved, both in terms of range alone is not a risk factor for development of osteoarthri- of motion and functional stability, younger athletes tis. Running will be discussed in greater detail in a sub- (younger than age 50 years) have opted for TKA in sequent section. an attempt to stay active, return to certain sports, and remain competitive.50 Box 28-1 illustrates current rec- Exercise programs to maintain strength and range of ommendations after knee arthroplasty for a wide variety motion in senior athletes are strongly supported in the of sports. Total joint arthroplasty is associated with literature.1,2,4,31,33,39,48 Exercise designed to maintain or improved function, improved quality of life, and longer improve muscular strength is especially important for life. In the past few years, technological advancement the senior athlete because of not only the general main- in this area of orthopedic surgery has allowed for more tenance of lean body mass but also the shock-absorbing sports to be considered “safe” after total joint replace- capacity of muscle that can support arthritic joints. Ex- ment and adequate rehabilitation. Athlete expectations ercise programs can decrease joint pain with functional for return to athletic activity are high, and the limits activities, but the long-term effectiveness in prevention of safe return to sport are constantly being challenged. of progression of OA is somewhat unclear.2,22,43,48 Spe- However, people who participate in athletic activity cifically, muscle training exercises that are performed in after joint replacement subject the prosthesis to in- closed kinetic chain positions increase joint stability and creased force, increased joint-bearing-surface wear, functionally train muscles as shock absorbers. Muscle, increased stress at the prosthetic–bone interface, and when strong and flexible, serves as a shock-absorbing

CHAPTER 28  The Senior Athlete 531 B O X 2 8 - 1 Recommended Activities after Knee Arthroplasty Allowed Allowed with No Consensus Not Recommended Bowling Experience Baseball Basketball Canoeing Horseback riding Fencing Football Cycling (stationary) Rowing Gymnastics Jogging Cycling (road) Skating (ice) Handball Soccer Dancing (ballroom) Skiing (cross-country) Hockey Volleyball Dancing (square) Skiing (downhill) Rock climbing Golf Stationary skiing Roller skating Hiking Tennis (doubles) Singles tennis Shuffleboard Squash/racquetball Swimming Weight lifting Walking (normal) Weight machines Walking (speed) Data from Healy WL, Sharma S, Schwartz B, et al. Athletic activity after total joint arthroplasty. J Bone Joint Surg Am 2008;90:2245-2252, based upon a survey of expert members of the Knee Society, conducted in 2005. The survey was based on expert opinion, not evidence. The trend for increasing athletic activity after total knee arthroplasty is based on improved outcomes, improvements in surgical technique, and innovations in joint implants. B O X 2 8 - 2 Sport Participation Recommendations after Hip Arthroplasty Allowed Allowed with No Consensus Not Recommended Bowling Experience Fencing Basketball Canoeing Cross-country skiing Baseball Football Cycling (stationary) Downhill skiing Gymnastics Jogging Cycling (road) Horseback riding Handball Soccer Dancing (ballroom) Ice skating Hockey Dancing (square) Rowing Rock climbing Golf Stationary skiing Squash/racquetball Hiking Tennis (doubles) Singles tennis Shuffleboard Weight lifting Volleyball Swimming Weight machines Walking (normal) Walking (speed) Data from Healy WL, Sharma S, Schwartz B, et al. Athletic activity after total joint arthroplasty. J Bone Joint Surg Am 2008;90:2245-2252, based upon a survey of expert members of the Hip Society, conducted in 2005. The survey was based on expert opinion, not evidence. The trend for increasing athletic activity after total hip arthroplasty is based on improved outcomes, improvements in surgical technique, and innovations in joint implants. higher potential for traumatic injury than those with astute therapist will provide an individualized plan for lower levels of activity.50 The return to sport after total return to activity based on all factors surrounding the joint arthroplasty typically takes about 6 months50 and surgery and any postoperative movement dysfunction. remains controversial based on the sport and the athlete. Return to sport is guided by the surgical procedure MOVEMENT DYSFUNCTION AND (minimally invasive vs. traditional approaches), surgeon ASSESSMENT IN THE SENIOR ATHLETE recommendations, and previous participation in athletic activity. Box 28-2 illustrates current recommendations, The examination of the active older adult should begin based on expert opinion, for return to sport after total with awareness of aging changes and high expectations joint arthroplasty for a wide variety of sports.50 Sur- for performance. For example, an awareness of fitness geons and therapists have a responsibility to recommend norms for specific tasks will help the therapist determine activities that promote long-term durability and health an individual’s fitness level. Currently, there are several of the prosthesis, and unfortunately there is little hard norm-referenced tests for older adults. These include the evidence on which to base recommendations.2,50 The Senior Fitness Test, YMCA fitness test, and ACSM fitness

532 CHAPTER 28  The Senior Athlete speed, power, and agility and therefore of all athletic activities. When these building blocks are decreased, tests. The use of norm-referenced, functional skill–based the older athlete may compensate quality and therefore tests is advocated because of the limitations of testing develop altered biomechanical habits to allow contin- impairments that may or may not relate to the functional ued performance of an activity. When required move- skill needed. Generally speaking, the aging athlete is ex- ments are changed to accommodate less than optimal amined in the same method as his or her younger athletic musculoskeletal integrity, negative changes and com- peer. A sport- or movement-specific examination is im- pensations such as altered joint arthrokinematics can perative to understanding the contributions of athletic occur.51 Accommodations to altered mobility and sta- activity to functional limitations or pain. Motion, related bility can produce inefficiency and thus require more to and produced by all the neuromusculoskeletal contri- energy, resulting in an increased chance of poor perfor- butions of the human body, although variable by age re- mance, pain and likelihood of injury, especially with mains the prerequisite for function. years of accumulation of these accommodations com- bined with the aging changes of the musculoskeletal Traditional rehabilitation approaches used with ath- system. letes are often based on identification of inflamed tissues (and subsequent symptomatic treatment of those tissues) The Selective Functional Movement Assessment rather than on the correction of the mechanical cause of (SFMA) is one way of quantifying the qualitative assess- the tissue irritation. The symptom-based approach ment of functional movement and is not a substitute for makes the assumption that the painful tissue is the the traditional examination process. Rather, the SFMA is source of the pain and subsequent dysfunction. Al- the first step in the functional orthopedic examination though clinicians are trained to examine both the local process, which serves to focus and direct choices made area of complaint and the whole patient, typically the during the remaining portions of the exam, which are sequence of assessment is specific to general, with the pertinent to the functional needs of the older athlete. The examination focused on reproducing the athlete’s pain. SFMA uses functional movement patterns to identify For example, if a senior athlete complained of knee pain, impairments that potentially alter specific functional the clinician typically would first observe and evaluate movements. The approach taken with the SFMA places the knee, attempting to provoke the senior athlete’s com- less emphasis on identifying the source of the symptoms plaint. Following this, the clinician might ask the patient and more on identifying the cause. An example of this to perform some general movements of function. By assessment scheme is illustrated with a runner who looking at the knee first, an opportunity was missed to presents with low back pain. Frequently, the symptoms watch the body move as a whole and lost is the overall associated with the low back pain are not examined in perspective of what the athlete can functionally achieve. light of other secondary causes such as hip mobility. All too often clinicians become too focused on the Lack of mobility at the hip is compensated for by special tests that serve to confirm a pathologic diagnosis increased mobility or instability of the spine. The global that they fail to refine, qualify, and quantify the func- approach taken by the SFMA would identify the cause tional parameters of the problem at hand. Reversing the of the low back dysfunction. sequence of assessment by examining gross movements before looking at component impairments, the therapist The authors believe that it is important to start with may determine where to focus specific assessment. a whole-body, functional approach such as the SFMA By taking this approach, gross movements may provoke prior to specific impairment assessments to direct the or reveal symptoms in the problem area as well as in evaluation in a systematic and constructive manner. other areas. Observing functional movements that the Traditional muscle length and strength as well as special patient is able or unable to perform and those that pro- tests are used subsequently to help the clinician identify duce pain may provide a clearer picture of the cause of the impairments associated with the dysfunctional move- the problem. One exception to initiating the examina- ment. In the case of a senior athlete, functional ability tion using functional movements is the presence of involves participation in sport at their desired level: chemical pain, that is, acute postsurgical or postinjury fitness, recreational, or competitive. inflammation. Pain or inflammation of chemical origin is capable of influencing and producing movement dys- The functional assessment process emphasizes the function. Initial treatment emphasis would be directed analysis of function to restore proper movement of locally in order to mediate the problem prior to a com- specific physical tasks.51 Use of movement patterns plete functional examination. with the application of specific stresses and overpres- sure serve to determine if dysfunction and/or pain are THE SELECTIVE FUNCTIONAL elicited. The movement patterns will also reaffirm or MOVEMENT ASSESSMENT redirect the focus of the musculoskeletal problem. Maintaining or restoring proper movement of specific Mobility and stability coexist to create efficient move- segments is a key to preventing or correcting musculo- ment in the human body. Mobility and stability are the skeletal pain.51 The SFMA also identifies where func- fundamental building blocks of strength, endurance, tional exercise may be beneficial and also provides

CHAPTER 28  The Senior Athlete 533 feedback regarding the effectiveness of such exercise. finding that may be the key to correcting the problem.51 A functional approach to exercise utilizes key specific The seven basic movements of the SFMA are listed in movements that are common to the senior athlete and further explained in Table 28-3. Each movement is regardless of the specific sport they participate in.52 performed first in the loaded position and then in the Exercise that uses repeated movement patterns re- unloaded position if dysfunction is observed in the quired for desired function is not only realistic but loaded position (Figures 28-9 to 28-16). practical and time efficient.52 The first five movements examine a combination of The Scoring System for the SFMA upper quarter, lower quarter, and trunk movements. The shoulder and cervical assessments examine upper The SFMA uses seven basic movement patterns to rate quarter movement quality. Each movement is graded and rank the two variables of pain and function. Func- with a notation of FN, FP, DP, or DN (see Box 28-3). tion comprises mobility and stability (Box 28-3). The All responses other than FN are then assessed in term functional describes any unlimited or unrestricted greater detail to help refine the movement information movement. The term dysfunctional describes move- and direct the clinical testing. Detailed algorithmic ments that are limited or restricted in some way, SFMA breakouts are available for each of the move- demonstrating a lack of mobility, stability, or symmetry ment patterns, but it is beyond the scope of this chap- within a given movement pattern. Painful denotes ter to describe. Once dysfunction and/or symptoms a situation where the selective functional movement have been provoked in a functional manner, it is neces- reproduces symptoms, increases symptoms, or brings sary to work backward to more specific assessments of about secondary symptoms that need to be noted. the component parts of the functional movement by Therefore, each pattern of the SFMA must be scored using special tests or range-of-motion comparisons. As with one of four possible outcomes. the gross functional movement is broken down into component parts, the therapist should examine for The seven basic movements or motions that comprise consistencies and inconsistencies as well as level of the basic SFMA screen look simple but require good dysfunction for each test as compared to the optimal flexibility and control. An older athlete who is (1) unable movement pattern. Provocation of symptoms as well to perform a movement correctly, (2) shows a major as limitations in movement or the inability to maintain limitation with one or more of the movement patterns, stability during movements should be noted. Biome- or (3) demonstrates an obvious difference between the chanical adaptations producing dysfunctional patterns left and right side of the body has exposed a significant are common in aging persons but should be considered having rehabilitation potential. B O X 2 8 - 3 Scoring System for the SFMA, Based Loaded and Unloaded Implications.  B​ y performing upon Function and Pain Reproduction parts of the test movements in both loaded and un- loaded conditions, the clinician can draw conclusions Label of Outcome of Description of Outcome about the interplay between the older adult’s available Pattern Performance Unlimited, unrestricted movement mobility and stability. If any of the first five movements Functional nonpainful (FN) are restricted when performed in the loaded position Functional painful (FP) that is performed without pain (e.g., limited, and/or in some way painful prior to the or increased symptoms end of the range of motion [ROM]) a clue is provided Dysfunctional painful (DP) Unlimited, unrestricted movement regarding functional movement. For example, if a that reproduces or increases movement is performed easily (does not provoke symp- Dysfunctional nonpainful symptoms or brings on toms or have any limitation) in an unloaded situation (DN) secondary symptoms it would seem logical that the appropriate joint ROM Movement that is limited or and muscle flexibility exist and therefore a stability restricted in some way, problem may be the cause of why the patient cannot demonstrating lack of mobility, perform the movement in a loaded position. In this stability, or symmetry, that case, a patient has the requisite available biomechani- reproduces or increases cal ability to go through the necessary ROM to per- symptoms, or brings on form the task, but the neurophysiological response secondary symptoms needed for stabilization that creates dynamic align- Movement that is limited or ment and postural support is not available when the restricted in some way, functional movement is performed. demonstrating lack of mobility, stability, or symmetry that is If the patient is observed to have a limitation, restric- performed without pain or tion, and pain when unloaded, the patient displays con- increased symptoms sistent abnormal biomechanical behavior of one or more joints and therefore would require specific clinical as- SFMA, Selective Functional Movement Assessment. sessment of each relevant joint and muscle complex to

534 CHAPTER 28  The Senior Athlete TA B L E 2 8 - 3 The Seven SFMA Tests The Top-Tier Test Description Reason for Test Scoring Criteria Tests Tests for normal flexion of the Touches toes without bending knees Posterior weight shift of pelvis 1 . Multisegmental Toe touch maneuver: hips, spine, and length of Uniform spinal curve flexion • Stand with feet together and toes the muscles of the lower No lateral spinal bend (Figure 28-9) back and legs. pointing forward. Arms extend to clear the ears. 2 . Multisegmental • Bend forward from the hips and Tests for normal extension in Anterior superior iliac spine moves ante- extension the UEs, hips, and spine. (Figure 28-10) try to touch the ends of the fin- rior over the toes. gers to the tips of the toes, with- This maneuver tests for normal Spine of the scapula moves posterior and 3. Multisegmental out bending the knees. rotational mobility in the rotation (R & L) Overhead UE reach with concurrent neck, trunk, pelvis, hips, clears the heels. (Figure 28-11) spine and hip extension: knees, and feet. Symmetrical spinal curves. • Stand with feet together and toes 4. Single-limb stance pointing forward. This is used to evaluate the Pelvis rotates .50 degrees. (R & L) • Raise the arms directly overhead patient’s ability to effectively Trunk rotates .50 degrees. (Figure 28-12) with arms extended, trying to get stabilize on each leg No loss of body height or extension of the elbows in line with the ears. independently for 10 s. 5. Overhead deep • Bend backward as far as possible trunk. squat making sure the hips go forward This maneuver is used to assess Symmetrical motion to the right and left. (Figure 28-13) and the arms go backward at the bilateral mobility of the hips, same time. knees, and ankles. When Eyes open .10 s 6. UE movement Total body rotation: combined with the hands Eyes closed .10 s patterns • Stand with the feet together, toes held overhead, this test also Level pelvis (no A. Medial rotation pointing forward, and the arms assesses bilateral mobility of with extension abducted away from the sides. the shoulders as well as ex- Trendelenburg) (Figure 28-14, A) • Rotate the entire body as far as tension of the No loss of height B. Lateral rotation possible to the right, using LE, thoracic spine. with flexion trunk and cervical rotation, re- Thighs break parallel, .90 degrees flexion. (Figure 28-15) maining upright (no extension). A. Assesses medial rotation, Hands stay over the feet (do not progress • Return to the starting position extension, and adduction and repeat to the left. of the shoulder. anterior). Single-limb balance test: Feet point forward. • Stabilize on one leg with the con- B. Assesses lateral rotation, Weight is evenly distributed between the tralateral LE flexed to 90 degrees, flexion, and abduction of attempt to hold for 10 s, eyes open the shoulder. two LEs. • Repeat on opposite limb • Repeat with the eyes closed, at- Compare both sides and look for gross tempt to hold for 10 s imbalances from right to left. Stand to squat activity: • Stand with feet shoulder width apart and toes facing straight ahead • Raise the UEs above the head and hold slightly wider than the feet • Instruct patient to squat all the way down while keeping the hands above the head. • Patient should be cued to perform a full deep squat with the heels remaining on the ground and the hands above their head without pain or discomfort. A. Back scratch B. Back patting

CHAPTER 28  The Senior Athlete 535 TA B L E 2 8 - 3 The Seven SFMA Tests—cont’d The Top-Tier Test Description Reason for Test Scoring Criteria Tests Is pain reproduced? Impingement test: This pattern Clearing tests: Provocation tests to look for glenohu- looks for impingement and A—Chin to chest: A. Impingement meral impingement, instability, a functional instability Limited movement can indicate a reduced sign capsular tightness, and AC joint problem of the (Figure 28-14B) pathology. glenohumeral joint. capacity of the short neck flexors and B. Horizontal may also indicate reduced mobility. adduction Horizontal adduction: Chin should touch sternum without pain. This pattern looks for AC joint B—Face to ceiling: 7. Cervical Flexion and extension motions alone, This move evaluates the amount of cervi- movement plus a combined motion of flexion, problems, anterior cal spine extension available. patterns side bending, and rotation (per- impingement, and posterior Face should extend to within 10 degrees (Figure 28-16) formed bilaterally). capsule tightness. of parallel without pain. Cervical spine clearing for C—Chin to shoulders: ranges of motion and This move is a combination pattern that muscular extensibility, incorporates side-bending and rotation. bilaterally. Normal range is midclavicle bilaterally without pain. (Mouth should stay closed). AC, acromioclavicular; LE, lower extremity; SFMA, selective functional movement assessment; UE, upper extremity. FIGURE 28-9  ​Multisegmental flexion test. FIGURE 28-10  ​Multisegmental extension test.

536 CHAPTER 28  The Senior Athlete FIGURE 28-11  M​ ultisegmental rotation test. FIGURE 28-13  ​Overhead deep squat test. FIGURE 28-12  S​ ingle-limb stance test. How to Interpret the SFMA identify the barriers that restrict movement and that may As mentioned earlier, each movement pattern should be be responsible for the provocation of pain. Consistent ranked and rated according to Box 28-3. The criteria limitation and provocation of symptoms in both the listed in Box 28-4 help to give qualitative analysis to the loaded and unloaded conditions may be indicative of a four possible descriptors (FN, FP, DP, DN). mobility problem.51 True mobility restrictions often re- quire appropriate manual therapy in conjunction with Once the SFMA has been completed, the therapist corrective exercise. should be able to do the following: (1) Identify the ma- jor sources of dysfunction and movements that are af- fected. (2) Identify patterns of movement that cause pain where reproduction of pain indicates either mechanical deformation or an inflammatory process affecting the nociceptors in the symptomatic structures. The key follow-up question must be “Which of the functional movements caused the tissue to become painful?” (3) Once the pattern of dysfunction has been identified, the problem is classified as either a mobility or stability dysfunction, determine where intervention should commence. With the SFMA, the choice of treatment is not about alleviating mechanical pain; rather the SFMA guides the therapist in choosing interventions designed to improve the dysfunctional nonpainful patterns first. This philoso- phy of intervention does not ignore the source of pain; rather, it takes the approach of removing the mechanical dysfunction that causes the tissues to become symptomatic in the first place. Pain-free functional movement is the goal of healthy aging. Pain-free functional movement necessary to

CHAPTER 28  The Senior Athlete 537 A FIGURE 28-15  ​Lateral rotation test. B GENERAL REHABILITATION FIGURE 28-14  ​A, Medial rotation test. B, Impingement pain CONSIDERATIONS FOR THE SENIOR ATHLETE reproduction test. The rehabilitation of injuries sustained by older athletes allow participation in sports is composed of many is approached in a similar manner to comparable prob- components: posture, ROM, muscle performance, and lems in younger athletes. In our experience, older ath- motor control. Impairments in any of these components letes respond well to treatment, but recovery takes lon- can potentially alter required functional movement. The ger as rate of tissue repair slows with age4,18,36 and which therapeutic plan of care needs to be focused on the may result in more residual dysfunction. For example, athletes’ functional impairments that are a result and/or when compared to a 20-year-old, a 60-year-old athlete cause of pathology. The clinician can then use the tradi- may require double the time and an athlete older than tional parts of the clinical examination to refine and age 75 years may require three times as long to return to deduce the specific pathoanatomic structures responsible sport.4,18 This does not, however, diminish the motiva- for the functional limitation. The authors believe the tion to return to sport, and the rehabilitation provider SFMA, though untested in research literature, incorpo- must remember to treat the injury, not the “age.” Many rates the essential elements of many sports activities and aspects of intervention common to the younger athlete provides a schema for addressing movement-related dys- can be generalized to the older athlete, but several function. More information can be obtained at www. unique differences inherent to the aging athlete must be functionalmovement.com. addressed and are described next. Pathologies related to normal consequences of aging as well as residual injuries affect older athletes’ response to training and rehabilitation.18 Systemic disease, degen- erative disease, and previous injury can have a significant impact on athletic performance in the older adult and will likely influence the choice of athletic activity. Sys- temic diseases whose incidence increases with age include cardiovascular disease and diabetes. Exercise has been shown to have a generally positive effect on these diseases.7,17,32,45,53 The therapist needs to be aware of the kinds of screening necessitated by the presence of sys- temic disease. For example, aging athletes with diabetes should be carefully examined for signs of foot problems related to diminished peripheral sensation secondary to degeneration of myelin and a compromised vascular

538 CHAPTER 28  The Senior Athlete A BC FIGURE 28-16  ​Cervical tests: A, Flexion; B, extension; C, combination pattern. (See Table 28-3.) BO X 2 8 - 4 Qualitative Questions for Assessing symptoms and functional limitations will guide the reha- Performance during the SFMA Tests bilitation professional in designing an appropriate plan of care, in spite of the presence of osteoarthritis. Degen- 1. Did performance of the test produce pain? If yes, you must score erative disc disease also can be a problem in the older DP or FP, depending on whether the pattern was performed athlete, but again, radiographic evidence is not sufficient functionally or dysfunctionally. to ascribe symptoms to its presence. Care should be taken to carefully evaluate other possible causes of pain, 2 . Is the pattern asymmetrical or symmetrical? If asymmetrical, you such as hypomobility, inflammation, and overuse. must score it a DP or DN, depending on whether pain is present. Impairments 3. For unilateral active movements, if the motion is symmetrical and equal, is the effort the athlete uses to perform the Movement patterns utilized by an individual are devel- movement perceived as equal? If not, score DP or DN depending oped by their activities, habits, hand dominance, and on whether pain is present. previous injuries. A temporary lack of activity may be the impetus for deterioration of movement patterns. 4. Does the performance of the movement fall under the “norms” A lack of variety of movements, sedentary lifestyle, pro- of performance, based on your clinical experience or published longed static postural stress, or poor body mechanics data? If yes, score FP or FN depending on whether pain is can all lead to muscular imbalances. Overuse activities present. frequently lead to adaptive shortening/tightening of muscles. Disuse may lead to weakening or inhibition of system resulting from arteriosclerosis. Other factors muscles. A common example of inhibition is the tighten- associated with diabetes mellitus include coronary com- ing of the iliopsoas, perhaps from prolonged sitting or plications, kidney failure, blindness, cataracts, and mus- ineffective recruitment of the gluteus maximus leading to cle weakness. Blood glucose should be carefully moni- the neurologic inhibition of its antagonist, the gluteus tored in the senior athlete with awareness of the effects maximus. Frequently, senior athletes will present with of intense performance on blood glucose levels.53 mobility dysfunction secondary to their aging musculo- skeletal system. True mobility restrictions often require Degenerative disease states, as previously mentioned, appropriate manual therapy in conjunction with correc- occur in most older individuals.4,44,48,50 Although senior tive exercise. For example, evidence exists for the effec- athletes may have radiographic evidence of osteoarthri- tiveness for joint mobilizations addressing capsular tis, careful physical examination is essential before the restrictions in aging joints.54,55 Soft tissue restrictions osteoarthritis can be incriminated as the cause of exer- may be treated with manual therapy and/or stretching. cise-related symptoms. Frequently, the presence of osteo- The patient may be taught to perform their own soft arthritis is sufficient for a physician or rehabilitation tissue mobilizations, static or dynamic stretches, or self- professional to attribute activity-related pain to arthritis, mobilizations to reinforce the manual work done in the when in fact it may be mere coincidence that the clinic (Figure 28-17). Once the patient has the mobility patient’s complaint is in the general area of a joint with osteoarthritis. Careful attention to the onset and mechanism of injury and the subsequent presentation of

CHAPTER 28  The Senior Athlete 539 FIGURE 28-17  ​Seated yoga stretch for trunk rotation, performed the mobility, stability, and neuromuscular performance of the core prevents injury and enhances sport perfor- by 87-year-old yoga practitioner, group leader. mance in both upper- and lower-extremity–dominant sports. Although not new, the concept of proximal sta- to perform the movement, they may progress to correc- bility to facilitate distal mobility is frequently overlooked tive exercises. in orthopedic and sports rehabilitation. If the problem is determined to be a stability dysfunc- The spinal column, essentially a stack of blocks that tion, frequently the clinician will need to use external sit atop one another, acts as the anchor for the remain- stabilization techniques or teach the patient to recruit ing skeletal parts (the extremities). The position of the certain key stabilizing muscles before an exercise pro- base of the spinal column along with the position of the gram can begin. This may include the use of taping pro- pelvis determines to a great extent the functional posi- cedures, supports or braces, PNF patterns, abdominal tion of the extremities during movement. Anterior– stabilization techniques, as well as functional corrective posterior trunk muscular balance determines pelvic exercises. Senior athletes may have compromised stabil- position, and along with efficient neuromuscular pro- ity because of a long history of incorrect or repetitive grams of the transversus abdominis and the multifidi movements throughout their lifetime. It is never too late serve to provide a stable base on which the lower ex- to teach proper movement within the confines of correct tremities can function. Trunk and pelvic muscle length, movement patterns and optimal stability. It is important strength, and motor control should be evaluated in all to remember that mobility problems take precedence athletes, and imbalances or poor performance should over stability problems: the clinician MUST correct be addressed, attempting to see and rectify “big pic- mobility deficiencies before stability. In accordance with ture” problems relating to core imbalances or instabil- the SFMA guidelines, corrective exercises are initiated ity. This principle is especially important in the senior for those movements that are dysfunctional and non- athlete because of the typical postural changes often painful (DN) first. The chosen corrective exercise should exhibited in the aging population that affects balance challenge the patient, yet they should be able to perform and efficiency of movement. The authors believe that it correctly. Incorrect performance will only further rein- addressing core function and control in all senior ath- force the faulty motor pattern, resulting in suboptimal letes is important, regardless of the primary site of outcomes. injury. This is especially true in the case of overuse injuries where improper biomechanical stresses may Big Picture: Core and Balance lead to dysfunction over a prolonged period of time. Balancing the musculature and “re-educating” motor A brief discussion of core stability is important to excel- programs involves a combination of many interven- lent treatment of the senior athlete. The authors believe tions, including exercises for the transverse abdominals that many therapists overlook the importance of the and multifidi, teaching diaphragmatic breathing, as trunk and its impact on efficiency of movement, yet well as enhancing the function of the gluteals (Figures trunk function, also known as core stability, plays a key 28-18 and 28-19). Exhalation during a forceful sport- role in returning the senior athlete to preinjury level of ing technique, such as the backhand stroke in tennis training and competition. When appropriate, improving FIGURE 28-18  A​ bdominal stabilizing exercises in supine using the Stabilizer for biofeedback. Focus is on transversus abdominis and multifidus to stabilize against limb movement.

540 CHAPTER 28  The Senior Athlete FIGURE 28-19  A​ bdominal stabilizing exercises in prone using the Stabilizer for biofeedback. Focus is on transversus abdominis and multifidus against limb movement. may assist the senior athlete in achieving a rigid trunk FIGURE 28-21  C​ losed-chain lower extremity strengthening (squat) that provides a stable base on which to move. Strength.  A​ trophy of skeletal muscle is a well-known performed by a senior athlete. consequence of aging. Muscular hypertrophy and strength is much easier to lose than to gain, and positive How much of this muscular strength decline is related to adaptations in skeletal muscle that occur as a result of inactivity and can be prevented by consistent, well- resistance training can begin to reverse in as little as targeted progressive resistive training? Collectively, the 48 hours.56 As skeletal muscle mass decreases, an associ- available literature supports that muscular hypertrophy ated reduction in muscle strength and general function and strength increases between 7% and 174% with re- often occurs. Muscular resistive training programs have sistance training depending on training dose (intensity been a cornerstone of fitness and wellness regimens used and sets), and improved neural or functional adaptations by athletes regardless of age, and may be especially im- occur similarly in young and older individuals.58-61 The portant as they have been shown to prevent or partially exact method by which strength training influences reverse age-related muscular atrophy (Figures 28-20 and sarcopenia remains controversial, and could be related 28-21).18,22,23,27,29,57,58 Such programs serve as an impor- to whole muscle factors (mass, hypertrophy) or myocel- tant method to maintain lean body mass and combat the lular level qualities.27 Skeletal muscle plasticity and sub- typical decrease in lean–fat body mass ratios that occur sequent response to training markedly diminishes after during aging. Strength and lean body mass typically the age of 80 years, and therefore Raue et al suggested peak in the third decade of life, and subsequently that all older individuals should engage in resistance decline thereafter as a normal consequence of aging. training in the sixth and seventh decades in order to maintain and gain muscular mass to remain functional FIGURE 28-20  S​ houlder press performed by a senior athlete. into the eighth and ninth decades.27 Senior athletes are best served by being directed to maintain a muscular resistance training program as an integral part of their training. Stretching.  I​njury prevention has always been an inte- gral part of sports physical therapy. Flexibility decreases with age, and this may affect tissue tolerance of the many demands of a wide variety of sporting activities. Because even a minor injury can lead to a dramatic de- crease in the senior athlete’s sports participation, preven- tion is extraordinarily important for the senior athlete. There is moderate to strong evidence that the routine application of static stretching does not reduce overall injury rates, and preliminary evidence that it may posi- tively affect the rates of musculotendinous injury.62,63 Improper or inconsistent stretching techniques, for

CHAPTER 28  The Senior Athlete 541 example, ballistic techniques, can cause muscle strains low-velocity, nonballistic stretching is best for the mus- and soreness, especially in the aging athlete whose flexi- cles and soft tissues of the aging athlete. Stretching in bility is decreasing. Although it may not be harmful, functional patterns and with low-velocity sport-specific statically stretching a cold muscle is not as efficient as movements may be helpful to prepare for athletic activ- stretching a warm muscle. There is some evidence for the ity. It seems logical to suggest stretching as a remedy for necessity of holding a static stretch for 60 seconds in the flexibility changes that occur with aging. However, it older persons as compared with 30 seconds in younger should be noted that the reason for the loss of flexibility persons (Figure 28-22).64 or range of motion with aging may be less a result of soft tissue tightness and more a result of joint changes. Some Warm-Up.  I​n the opinion of the authors, there is no changes include joint surface deterioration, breakdown substitute for an adequate warm-up by senior athletes of the collagen fibers, and a decrease in the viscosity before exercise. Athletes who have always avoided this of synovial fluid. In these cases, stretching may not be aspect of training find it increasingly essential as they particularly helpful. age. The best warm-up for a specific activity is 10 to 15 minutes of low-intensity engagement in that activity Sport-Specific Training and the SAID in order to increase intramuscular temperature of the Principle requisite muscles.62,65 For example, if tennis is the activ- ity, then the players should begin by total body move- Two important and closely related concepts are sport- ments for warm-up, progress to hitting balls across the specific training (SST) and the specific adaptations to net, slowly at first and then with increased velocity and imposed demands (SAID) principle.66 SST is defined as movement. If running is the activity, the runner should training that consists of stretching, strengthening, and begin the few minutes walking and progressing to an aerobic or anaerobic conditioning that is targeted to easy jog, gradually picking up speed. This rule is easily optimally prepare an athlete for his or her chosen generalized to other sports. sport.67 SAID principle uses similar thinking and ap- plies specificity of training by imposing demands on the Warm-up is often confused with stretching. Although athlete that simulate or reinforce his or her sport. “De- stretching may be a component of the warm-up for some mands” that can be incorporated include speed of mo- athletes, stretching can be as much of a problem as it can tions, sport patterns, or specific exercise movements in help, and outcomes of the research exploring the effects the context of the athlete’s chosen sport. Both princi- of preparticipation stretching are mixed. Muscle can be ples require the therapist to understand and “impose” adequately warmed by the previously mentioned warm- correct demands on athletes, no matter their age, in up techniques, and the authors suggest that older ath- order to return them to sport. Therefore, careful selec- letes engage in more global activities to warm the mus- tion of the proper interventions will allow the therapist cles before stretching or, even better, to incorporate to best prepare an athlete for return. The SFMA relates stretching into their cool-down routine. As a rule of well to both the SAID principle and the SST principles. thumb, athletes who have always stretched before exer- By using the fundamental movements inherent to the cise should not be discouraged from doing so. In general, SFMA to identify impaired movement patterns, the therapist will be led directly to specific interventions FIGURE 28-22  ​Hamstring stretch in senior tennis athlete. Note: that promote improved functional abilities. Each of these fundamental movements provides a glimpse into This athlete has had bilateral total knee replacements. foundational movement patterns on which ADLs and athletic ability are constructed. An excellent example of this is the deep squat maneuver. Many ADLs and ath- letic movements incorporate squatting motions (unilat- eral or bilateral) in their performance. If the deep squat test is impaired, at a low level, sit-to-stand function is impaired, and at a higher level, jumping or propulsion would be impaired. The Drive to Compete and Remain Active “Muscle mass declines, but determination doesn’t”2 depicts the senior athletes’ amazing desire to continue training and competing in their chosen sport. The physi- cal therapist must understand and acknowledge this fact and realize that although senior athletes may take longer to rehabilitate, their eagerness to return to sport is no