Susan O sullivan Raymond Siegelman National Phy

CHAPTER 8 GERIATRIC PHYSICAL THERAPY Susan B. O'Sullivan I. Foundations of Geriatric Physical Therapy 8. Ageism: discrimination and prejudice leveled against individuals on the basis of their age. A. General Concepts and Definitions of Aging 1. Aging: the process of growing old; describes a B. Demographics, Mortality, and Morbidity wide array of physiological changes in the body 1. Persons over 65: represents a rapidly growing seg- systems; complex and variable. ment with lengthening of life expectancy; currently a. Common to all members of a given species. 12.5% of U.S. population; by year 2030, expected b. Progressive with time. over 65 population will be 22% of US population. c. Evidenced by a: a. Older women outnumber older men; 145 (1) Decline in homeostatic efficiency. women for every 100 men. (2) Increasing probability that reaction to b. Caucasians represent about 90% of persons injury will not be successful. over 65; only 10% are non-white (8% black). d. Varies among and within individuals. 2. Increased life expectancy, aging of the population 2. Gerontology: the scientific study of the factors due to: impacting the normal aging process and the effects a. Advances in health care, improved infectious of aging. disease control. 3. Geriatrics: the branch of medicine concerned with b. Advances in infant/child care, decreased mor- the illnesses of old age and their care. tality rates. 4. Life span: maximum survival potential, the inherent c. Improvements in nutrition and sanitation. natural life of the species; in humans 110-120 years. 3. Leading causes of death (mortality) in persons 5. Life expectancy: the number of years of life expec- over 65, in order of frequency. tation from year of birth, 75.8 years in U.S.; a. Coronary heart disease (CHD), accounts for women live 6.6 years longer than men. 31 % of deaths. 6. Senescence: last stages of adulthood through death. b. Cancer, accounts for 20% of deaths. 7. Categories of elderly. c. Cerebrovascular disease (stroke). a. Young elderly: ages 65-74 (60% of elderly d. Chronic obstructive pulmonary di ease (COPD). population) . e. Pneumonia/flu. b. Old elderly: ages 75-84. 4. Leading causes of disability/chronic conditions c. Old, old elderly or old & frail elderly: ages> 85. (morbidity) in persons over 65, in order of frequency.

a. Arthritis, 49%. Geriatric Physical Therapy 253 b. Hypertension, 37%. c. Hearing impairments, 32%. genes are programmed to modulate aging d. Heart impairments, 30%. changes, overall rate of progression. e. Cataracts and chronic sinusitis, 17% each. (1) Individuals vary in the expression of aging f. Orthopedic impairments, 16%. g. Diabete and vi ual impairments, 9% each. changes, e.g., graying of hair, wrinkles, etc. h. Most older persons (60-80%) report having one (2) Polygenic controls exist (multiple genes or more chronic conditions. are involved): no one gene can modulate 5. Socioeconomic factors. rate of development in all aspects of aging. (3) Premature aging syndromes (progeria) pro- a. Half of all older women are widows; older men vide evidence of defective genetic program- twice a likely to be married as older women. ming; individuals exhibit premature aging changes, i.e., atrophy and thinning of tis- b. Most live on fixed incomes: social security is sues, graying of hair, arteriosclerosis, etc. the major source of income; poverty rate for (a) Hutchinson-Gilford syndrome: proge- per ons over 65 is 11.4%; another 8% live near the poverty rate. ria of childhood. (b) Werner's syndrome: progeria of young c. About half of older persons have completed high school. adults. b. Doublinglbiologic clock (Hayflick limit theo- d. Non-institutionalized elderly: most live in family setting. ry): functional deterioration within cells is due to limited number of genetically programmed e. Institutionalized elderly: about 5% of persons cell doublings (cell replication). over 65 reside in nursing homes; percentage c. Free radical theory: free radicals are highly increa es dramatically with age (22% of per- reactive and toxic forms of oxygen produced son over 85). by cell mitochondria; the released radicals. (1) Cause damage to cell membranes and DNA 6. Health care costs. a. Older persons account for 12% of population cell replication. and 36% of total health care expenditures. (2) Interfere with cell diffusion and transport, b. Older per ons account for 33% of all hospital stays, 44% of all hospital days of care. resulting in decreased 02 delivery and tissue death. C. Theories of Aging (3) Decrease cellular integrity, enzyme activities. 1. Aging is developmental, occur across the life span. (4) Result in cross-linkages: chemical bonding 2. Aging change . of elements not generally joined together; a. Cellular changes. interferes with normal cell function. (1) Increase in size; fragmentation of Golgi (5) Result in accumulation of aging pigments, apparatus and mitochondria. lipofuscins. (2) Decrease in cell capacity to divide and (6) Can trigger pathologic changes: atheroscle- reproduce. rosis in blood vessel wall; cell mutations (3) Arrest of DNA synthesis and cell division. and cancer. b. Tissue changes. d. Cell mutation (intrinsic mutagenesis): errors in (1) Accumulation of pigmented materials, the synthesis of proteins (DNA, RNA) leads to lipofu cins. exponential cascade of abnormal proteins and (2) Accumulation of lipids and fats. aging changes. (3) Connective tissue changes: decreased elastic e. Hormonal theory: functional decrements in content, degradation of collagen; presence neurons and their associated hormones lead to of pseudoelastins. aging changes. c. Organ changes. (1) Hypothalamus, pituitary gland, adrenal (I) Decrease in functional capacity. gland are the primary regulators, timekeep- (2) Decrease in homeostatic efficiency. ers of aging. 3. Biological theories. (a) Thyroxine is the master hormone of a. Genetic: aging is intrinsic to the organism; the body; controls rate of protein syn- thesis and metabolism.

254 life satisfaction. b. Disengagement theory: distancing of an indi- (b) Secretion of regulatory pituitary hor- mones influence thyroid. vidual or withdrawal from society; reduction in social roles leads to further isolation and life (2) Decreases in protective hormones: estro- dissatisfaction. gen, growth hormone, adrenal DHEA c. Dependency: increasing reliance on others for (dehydroepiandrosterone). meeting physical and emotional needs; focus is increasingly on self. (3) Increases in stress hormones (cortisol): can 7. An integrated model of aging assumes aging is a damage brain's memory center, the hip- complex, multifactorial phenomenon in which pocampus, and destroy immune cells. some or all of the above processes may contribute to the overall aging of an individual; aging is not f. Immunity theory: thymus size decreases, shriv- adequately explained by any single theory. els by puberty, becomes less functional; bone marrow cell efficiency decreases; results in II. Physiologic Changes and Adaptation in steady decrease in immune responses during adulthood. the Older Adult (1) Immune cells, T-cells, become less able to fight foreign organisms; B-cells become A. Muscular less able to make antibodies. 1. Age-related changes. (2) Autoimmune diseases increase with age. a. Changes may be due more to decreased activi- ty levels (hypokinesis) and disuse than from 4. Environmental theories (stochastic or non-genetic aging process. theories). b. Loss of muscle strength: peaks at age 30, a. Aging is caused by an accumulation of insults remains fairly constant until age 50; after from the environment. which there is an accelerating loss, 20-40% b. Environmental toxins include: ultraviolet, cross- loss by age 65 in the non-exercising adult. linking agents (unsaturated fats), toxic chemi- c. Loss of power (force/unit time): significant cals (metal ions, Mg, Zn), radiation, viruses. declines, due to losses in speed of contraction, c. Can result in: errors in protein synthesis and in changes in nerve conduction and synaptic DNA synthesis/genetic sequences (error theo- transmission. ry), cross-linkage of molecules, mutations. d. Loss of skeletal muscle mass (atrophy): both size and number of muscle fibers decrease, by 5. Psychological theories. age 70 lose 33% of skeletal muscle mass. a. Stress theory: homeostatic imbalances result in e. Changes in muscle fiber composition: selective changes in structural and chemical composition. loss of Type II, fast twitch fibers, with increase (1) General Adaptation Syndrome (Selye): initial in proportion of Type I fibers. alarm reaction, progressing to stage of resist- f. Changes in muscular endurance: muscles ance, progressing to stage of exhaustion. fatigue more readily. (2) Closely linked to hormonal theory. (1) Decreased muscle tissue oxidative capacity. b. Erickson's bipolar theory of lifespan develop- (2) Decreased peripheral blood flow, oxygen ment. Stages of later adulthood. delivery to muscles. (1) Integrity: individual exhibits full unification (3) Altered chemical composition of muscle: of personality; life is viewed with satisfac- decreased myosin ATPase activity, glyco- tion (productive life, sense of satisfaction), proteins and contractile protein. remains optimistic, continues to grow. (4) Collagen changes: denser, irregular due to (2) Despair: individual lacks ego integration; cross-linkages, loss of water content and life is viewed with despair (fear of death, elasticity; affects tendons, bone, cartilage. feelings of regret and disappointment, 2. Clinical implications. missed opportunities). a. Movements become slower. b. Movements fatigue easier; increased com- 6. Sociological theories: life experience/lifestyles plaints of fatigue. influence aging process. a. Activity theory: older persons who are socially active exhibit improved adjustment to the aging process; allows continued role enactment essential for positive self-image and improved

c. Connective tis ue becomes denser and stiffer. Geriatric Physical Therapy 255 (1) Increased risk of muscle sprains, strains, tendon tears. ized 80 and 90 year-olds. (2) Loss of range of motion: highly variable by (4) Improvements in strength correlate to joint and individual; activity level. (3) Increa ed tendency for fibrinous adhesions, improved functional abilities. contractures. d. Provide flexibility, range of motion exercises. d. Decrea ed functional mobility, limitations to (1) Utilize slow, prolonged stretching, main- movement. tained for 20-30 seconds. e. Gait changes. (2) Tissues heated prior to stretching are more (1) Stiffer, fewer automatic movements. distensible, e.g., warm pool. (2) Decreased amplitude and speed, slower cadence. (3) Maintain newly gained range: incorporate (3) Shorter steps, wider stride, increased double into functional activities. support to ensure safety, compensate for decreased balance. (4) Mobility gains are slower with older adults. (4) Decreased trunk rotation, arm swing. B. Skeletal System (5) Gait may become unsteady due to changes in balance, strength; increased need for 1. Age-related changes. assistive devices. a. Cartilage changes: decreased water content, becomes stiffer, fragments and erodes; by age f. Clinical ri k of falls. 60 more than 60% of adults have degenerative 3. Interventions to low or reverse changes. joint changes, cartilage abnormalities. b. Loss of bone mass and density: peak bone mass a. Improve health. at age 40; between 45 and 70 bone mass (1) Correction of medical problems that may decreases (women by about 25%; men 15%); cause weakness: hyperthyroidism, excess decreases another 5% by age 90. adrenocortical teroids (e.g., Cushing's dis- (1) Loss of calcium, bone strength: especially ease, steroids); hyponatremia (low sodium trabecular bone. in blood). (2) See discussion of osteoporosis under (2) Improve nutrition. pathological manifestations of aging. (a) Correction of hyponatremia. (3) Decreased bone marrow red blood cell pro- (b) Increased fatigue associated with diar- duction. rhea, prolonged use of diuretics. c. Intervertebral discs: flatten, less resilient due to (3) Address alcoholism. loss of water content (30% loss by age 65) and loss of collagen elasticity; trunk length, overall b. Increase levels of physical activity, stress func- height decreases. tional activities and activity programs. d. Senile postural changes. (1) Gradual increase in intensity of activity to (1) Forward head. avoid injury. (2) Kyphosis of thoracic spine. (2) Adequate warm ups and cool downs; (3) Flattening of lumbar spine. appropriate pacing and rest periods. (4) With prolonged sitting, tendency to develop hip and knee flexion contractures. c. Provide strength training. (1) Significant increases in strength noted in 2. Clinical implications. older adults with isometric and progressive a. Maintenance of weight-bearing is important resistive exercise regimes. for cartilaginous/joint health. (2) High-intensity training programs (70-80% b. Clinical risk of fractures. of one-repetition maximum) produce quicker and more predictable results than 3. Interventions to slow or reverse changes. moderate intensity programs; both have a. Postural exercises: stress components of good been successfully used with the elderly. posture. (3) Age not a limiting factor: significant b. Weight bearing (gravity-loading) exercise can improvements noted in frail, institutional- decrease bone loss in older adults, e.g., walk- ing; stair climbing; weight belts can increase load. c. Nutritional, hormonal and medical therapies: see discussion of osteoporosis.

256 2. Clinical implications. a. Effects on movement. C. Neurological System (1) Overall speed and coordination are 1. Age-related changes. decreased; increased difficulties with fine a. Atrophy of nerve cells in cerebral cortex: over- motor control. all loss of cerebral mass/brain weight of 6-11 % (2) Slowed recruitment of motoneurons con- between ages of 20 and 90; accelerating loss tributes to loss of strength. after age 70. (3) Both reaction time and movement time are b. Changes in brain morphology. increased. (1) Gyral atrophy: narrowing and flattening of (4) Older adults are affected by the speed! gyri with widening of sulci. accuracy trade off. (2) Ventricular dilation. (a) The simpler the movement, the less the (3) Generalized cell loss in cerebral cortex: change. especially frontal and temporal lobes, asso- (b) More complicated movements require ciation areas (prefrontal cortex, visual). more preparation, longer reaction and (4) Presence of lipofuscins, senile or neuritic movement times. plaques, and neurofibrillary tangles (NFf): (c) Faster movements decrease accuracy, significant accumulations associated with increase errors. pathology, e.g., Alzheimer's dementia. (5) Older adults typically shift in motor control (5) More selective cell loss in basal ganglia processing from open to closed loop: e.g., (substantia nigra and putamen), cerebel- demonstrate increased reliance on visual lum, hippocampus, locus coeruleus; brain- feedback for movement. stem minimally affected. (6) Demonstrate increa ed cautionary behav- c. Decreased cerebral blood flow and energy iors, an indirect effect of decreased capacity. metabolism. b. General slowing of neural processing: learning d. Changes in synaptic transmission. and memory may be affected. (1) Decreased synthesis and metabolism of c. Problems in homeostatic regulation: stressor major neurotransmitters, e.g., acetylcholine, (heat, cold, excess exerci e) can be harmful, dopamine. even life-threatening. (2) Slowing of many neural processes, espe- cially in polysynaptic pathways. 3. Interventions to slow or reverse changes. e. Changes in spinal cord/peripheral nerves. a. Correction of medical problems: improve cere- (1) Neuronal loss and atrophy: 30-50% loss of bral blood flow. anterior hom cells, 30% loss of posterior b. Improve health: diet, smoking cessation. roots (sensory fibers) by age 90. c. Increase levels of physical activity: may (2) Loss of motoneurons results in increase in encourage neuronal branching, slow rate of size of remaining motor units (development neural decline, improve cerebral circulation. of macro motor units). d. Provide effective strategies to improve motor (3) Slowed nerve conduction velocity: sensory learning and control. greater than motor. (1) Allow for increased reaction and move- (4) Loss of sympathetic fibers: may account ment times: will improve motivation, accu- for diminished, autonomic stability, racy of movements. increased incidence of postural hypoten- (2) Allow for limitations of memory: avoid sion in older adults. long sequences of movement . f. Age-related tremors (essential tremor, ET). (3) Allow for increased cautionary behaviors: (1) Occur as an isolated symptom, particularly provide adequate explanation, demonstra- in hands, head and voice. tion when teaching new movement skills. (2) Characterized as postural or kinetic, rarely (4) Stress familiar, well-leamed kills; repetitive resting. movements. (3) Benign, slowly progressive; in late stages may limit function. D. Sensory Systems (4) Exaggerated by movement and emotion. 1. Age-related changes: older adults experience a

loss of function of the senses; alters quality of life, Geriatric Physical Therapy 257 ability to interact socially and with the environ- ment. impairment; complete blindness is rare. a. May lead to ensory deprivation, isolation, dis- (5) CVA, homonymous hemianopsia: loss of orientation, confusion, appearance of senility. 112 visual field in each eye (nasal half of b. May strain social interactions. one eye and temporal half of other eye); c. May lead to decreased functional mobility, risk produces an inability to receive information from right or left side; corresponds to side of injury. of sensorimotor deficit. 2. Vision. (6) Medications: impaired or fuzzy vision may result with antihistamines, tranquilizers, a. Aging changes: there is a general decline in anti-depressants, steroids. vi ual acuity; gradual prior to sixth decade, c. Clinical implications/compensatory strategies. rapid decline between ages 60 and 90; visual (1) Examine vision: acuity, peripheral vision, loss may be as much as 80% by age 90. light and dark adaptation, depth perception; (1) Presbyopia: visual loss in middle and older diplopia, eye fatigue, eye pain. ages characterized by inability to focus (2) Maximize visual function: assess for use of properly and blurred images, due to loss of glasses, need for environmental adaptations. accommodation, elasticity of lens. (3) Sensory thresholds are increased: allow (2) Decreased ability to adapt to dark and light. extra time for visual discrimination and (3) Increased sensitivity to light and glare. response. (4) Loss of color discrimination, especially for (4) Work in adequate light, reduce glare; avoid blues and greens. abrupt changes in light, e.g., light to dark. (5) Decrea ed pupillary responses, size of rest- (5) Decreased peripheral vision may limit ing pupil increases. social interactions, physical function: stand (6) Decrea ed sensitivity of corneal reflex: less directly in front of patient at eye level when sensitive to eye injury or infection. communicating with patient. (7) Oculomotor responses diminished: restrict- (6) Assist in color discrimination: use warm ed upward gaze, reduced pursuit eye move- colors (yellow, orange, red) for identifica- ments; ptosis may develop. tion and color coding. (7) Provide other sensory cues when vision is b. Additional vision loss with pathology. limited: e.g., verbal descriptions to new (1) Cataracts: opacity, clouding of lens due to environments, touching to communicate changes in lens proteins; results in gradual you are listening. loss of vision: central first, then peripheral; (8) Provide safety education; reduce fall risk. increased problems with glare; general dark- 3. Hearing. ening of vision; loss of acuity, distortion. a. Aging changes: occur as early as fourth (2) Glaucoma: increased intraocular pressure, decade; affects a significant number of elderly with degeneration of optic disc, atrophy of (23% of individuals aged 65-74 have hearing optic nerve; results in early loss of periph- impairments and 40% over age 75 have hearing eral vision (tunnel vision), progressing to loss; rate of loss in men is twice the rate of total blindness. women, also starts earlier). (3) Senile macular degeneration: loss of cen- (1) Outer ear: buildup of cerumen (ear wax) tral vision associated with age-related may result in conductive hearing loss; com- degeneration of the macula compromised mon in older men. by decreased blood supply or abnormal (2) Middle ear: minimal degenerative changes growth of blood vessels under the retina; of bony joints. initially patients retain peripheral vision; (3) Inner ear: significant changes in sound sen- may progress to total blindness. sitivity, understanding of speech, and main- (4) Diabetic retinopathy: damage to retinal cap- tenance of equilibrium may result with illaries, growth of abnormal blood vessels degeneration and atrophy of cochlea and and hemorrhage leads to retinal scarring and vestibular structures, loss of neurons. finally retinal detachment; central vision

258 (3) Altered sensory organization: older adults more dependent upon somatosensory b. Types of hearing loss. inputs for balance. (1) Conductive: mechanical hearing loss from damage to external auditory canal, tympan- (4) Less able to resolve sensory conflicts when ic membrane or middle ear ossicles; results presented with inappropriate visual or pro- in hearing loss (all frequencies); tinnitus prioceptive inputs due to vestibular losses. (ringing in the ears) may be present. (2) Sensorineural: central or neural hearing loss (5) Postural response patterns for balance are from multiple factors, e.g., noise damage, disorganized: characterized by diminished trauma, disease, drugs, arteriosclerosis, etc. ankle torque, increased hip torque, (3) Presbycusis: sensorineural hearing loss increased postural sway. associated with middle and older ages; characterized by bilateral hearing loss, b. Additional loss of vestibular sensitivity with especially at high frequencies at fIrst, then pathology. all frequencies; poor auditory discrimina- (1) Meniere's disease: episodic attacks charac- tion and comprehension, especially with terized by tinnitus, dizziness, and a sensa- back ground noise; tinnitus. tion of fullness or pressure in the ears; may also experience sensorineural hearing loss. c. Additional hearing loss with pathology. (2) Benign paroxysmal positional vertigo (1) Otosclerosis: immobility of stapes results (BPPV): brief episodes of vertigo (less than in profound conductive hearing loss. 1 minute) associated with position change; (2) Paget's disease. the result of degeneration of the utricular (3) Hypothyroidism. otoconia that settle on the cupula of the posterior semicircular canal; common in d. Clinical implications/compensatory strategies. older adults. (1) Examine hearing: acuity, speech discrimi- (3) Medications: antihypertensives (postural nation/comprehension; tinnitus, dizziness, hypotension); anticonvulsants; tranquiliz- vertigo, pain. ers, sleeping pills, aspirin, NSAIDS. (2) Measure air and bone conduction: Rinne (4) Cerebrovascular disease: vertebrobasilar test, Weber test. Refer to Chapter 2. artery insufficiency (TIAs, strokes); cerebel- (3) Determine use of hearing aids; check for lar artery stroke, lateral medullary stroke. proper functioning. (5) Cerebellar dysfunction: hemorrhage, (4) Minimize auditory distractions: work in tumors (acoustic neuroma, meningioma); quiet environment. degenerative disease of brainstem and cere- (5) Speak slowly and clearly, directly in front bellum; progressive supranuclear palsy. of patient at eye level. (6) Migraine. (6) Use nonverbal communication to reinforce (7) Cardiac disease. your message, e.g., gesture, demonstration. (7) Orient person to topics of conversation they d. Clinical implications/compensatory strategies. cannot hear to reduce paranoia, isolation. (1) Increased incidence of falls in older adults. (2) Refer to section on falls and instability. 4. Vestibularlbalance control. a. Aging changes: degenerative changes in otoco- 5. Somatosensory. nia of utricle and saccule; loss of vestibular a. Aging changes. hair-cell receptors; decreased number of (1) Decreased sensitivity of touch associated vestibular neurons; VOR gain decreases; begins with decline of peripheral receptors, atro- at age 30, accelerating decline at ages 55-60 phy of afferent fIbers: lower extremities resulting in diminished vestibular sensation. more affected than upper. (1) Diminished acuity, delayed reaction times, (2) Proprioceptive losses, increased thresholds longer response times. in vibratory sensibility, beginning around (2) Reduced function of vestibular ocular age 50: greater in lower extremities than reflex (VOR); affects retinal image stabili- upper extremities, greater in distal extremi- ty with head movements, produces blurred ties than proximal. vision. (3) Loss of joint receptor sensitivity; losses in

lower extremities, cervical joints may con- Geriatric Physical Therapy 259 tribute to loss of balance. (4) Cutaneous pain thresholds increased: E. Cognition greater changes in upper body areas (upper I. Age-related changes. extremities, face) than for lower extremities. a. No uniform decline in intellectual abilities b. Additional loss of sensation with pathology. throughout adulthood. (1) Diabetes, peripheral neuropathy. (I) Changes do not typically show up until mid (2) CVA, central sensory losses. 60s; significant declines affecting everyday (3) Peripheral vascular disease, peripheral life do not show up until early 80s. ischemia. (2) Most significant decline in measures of c. Clinical implications/compensatory strategies. intelligence occur in the year immediately (1) Examine ensation: check for increased preceding death (termed terminal drop). thresholds to stimulation, sensory losses by b. Tasks involving perceptual speed: show early modality, area of body. declines (by age 39); require longer times to (2) Allow extra time for responses with complete tasks. increased thresholds. c. Numeric ability (tests of adding, subtracting, (3) Use touch to communicate: maximize multiplying): abilities peak in rnid-40s, well physical contact, e.g., rubbing, stroking. maintained until 60s. (4) Highlight, enhance naturally occurring d. Verbal ability: abilities peak at age 30, well intrinsic feedback during movements, e.g., maintained until 60s. stretch, tapping. e. Memory. (5) Provide augmented feedback through (1) Impairments are typically noted in short- appropriate sensory channels, e.g., walking term memory; long-term memory retained. on carpeted surfaces may be easier than on (2) Impairments are task dependent, e.g., mooth floor. deficits primarily with novel conditions, (6) Teach compensatory strategies to prevent new learning. injury to anesthetic limbs, falls. f. Learning: all age groups can learn; learning in (7) Provide assistive devices as needed for fall older adults affected by: prevention. (I) Increased cautiousness. (8) Provide biofeedback devices as appropriate (2) Anxiety. (e.g., limb load monitor). (3) Pace of learning: fast pace is problematic. 6. Taste and smell. (4) Interference from prior learning. a. Aging changes. 2. Clinical Implications. (1) Gradual decrease in taste sensitivity. a. Older adults utilize different strategies for (2) Decreased smell sensitivity. memory: context-based strategies v . memo- b. Additional loss of sensation. rization (young adults). (I) Smokers. b. Stress relationship, importance for function. (2) Chronic allergies, respiratory infections. 3. Interventions to slow or reverse changes. (3) Dentures. a. Improve health. (4) CVA, involvement of hypoglossal nerve. (1) Correction of medical problems: imbal- c. Clinical implications/compensatory strategies. ances between oxygen supply and demand (I) Examine ability to identify odors, tastes to CNS, e.g., cardiovascular disease, hyper- ( weet, sour, bitter, salty); somatic sensa- tension, diabetes, hypothyroidism. tions (temperature, touch). (2) Pharmacological changes: drug re-evalua- (2) Decreased taste, enjoyment of food leads to tion; decreased use of multiple drugs; mon- poor diet and nutrition. itor closely for drug toxicity. (3) Older adults frequently increase use of (3) Reduction in chronic use of tobacco and taste enhancers: e.g., salt or sugar. alcohol. (4) Decrea ed home safety: e.g., gas leaks, (4) Correction of nutritional deficiencies. smoke. b. Increase physical activity. c. Increase mental activity. (I) Keep mentally engaged \"Use it or Lose it\";

260 elderly due to reduced baroreceptor sensitivity and vascular elasticity. e.g., chess, crossword puzzles, high level of g. Increased fatigue; anemia common in elderly. reading. h. Systolic ejection murmur common in elderly. (2) Engaged lifestyle: socially active, e.g., 1. Possible ECG change : loss of normal sinus clubs, travel, work. rhythm; longer PR & QT intervals; wider QRS; (3) Cognitive training activities. increased arrhythmias. d. Auditory processing may be decreased: provide G. Pulmonary System written instructions. 1. Age-related changes. e. Provide stimulating, \"enriching\" environment; a. Chest wall stiffne s. declining strength of res- avoid environmental dislocation, e.g., hospital- piratory muscle results in increased work of ization or institutionalization may produce dis- breathing. orientation and agitation in some elderly. b. Loss of lung elastic recoil, decreased lung f. Reduction of stress: counseling and family sup- compliance. port. c. Changes in lung parenchyma: alveoli enlarge, F. Cardiovascular System become thinner; fewer capillaries for delivery 1. Age-related changes. of blood. a. Changes due more to inactivity and disease d. Changes in pulmonary blood vessels: thicken, than aging. less distensible. b. Degeneration of heart muscle with accumula- e. Decline in total lung capacity: residual volume tion of lipofuscins (characteristic brown heart); increases, vital capacity decreases. mild cardiac hypertrophy left ventricular wall. f. Forced expiratory volume (air flow) decrease. c. Decreased coronary blood flow. g. Altered pulmonary gas exchange: oxygen ten- d. Cardiac valves thicken and stiffen. sion falls with age (at a rate of 4mmHg/decade; f. Changes in conduction system: loss of pace Pa02 at age 70 is 75, versu 90 at age 20). maker cells in SA node. h. Blunted ventilatory responses of chemorecep- g. Changes in blood vessels: arteries thicken, less tors in response to respiratory acidosis: distensible; slowed exchange capillary walls; decreased homeostatic responses. increased peripheral resistance. i. Blunted defense/immune responses: decreased h. Resting blood pressures rise: systolic greater ciliary action to clear secretions, decreased than diastolic. secretory immunoglobulins, alveolar phagocytic i. Decline in neurohumoral control: decreased function. responsiveness of end-organs to beta-adrenergic 2. Clinical implications. stimulation of baroreceptors. a. Re piratory re pon es to exerci e: irnilar to j. Decreased blood volume, hemopoietic activity younger adult at low and moderate intensities; of bone. at higher intensities, responses include k. Increased blood coagulability. increased ventilatory cost of work, greater 2. Clinical implications. blood acidosis, increased likelihood of breath- a. Changes at rest are minor: resting heart rate and lessness, and increased perceived exertion. cardiac output relatively unchanged; resting b. Clinical signs of hypoxia are blunted; changes in blood pressures increase. mentation and affect may provide important cues. b. Cardiovascular responses to exercise: blunted, c. Cough mechanism i impaired. decrease in heart rate acceleration, decrease d. Gag reflex is decreased, increased risk of aspi- maximal oxygen uptake and heart rate; reduced ration. exercise capacity, increased recovery time. e. Recovery from respiratory illness: prolonged in c. Decreased stroke volume due to decreased the elderly. myocardial contractility. f. Significant changes in function with chronic smok- d. Maximum heart rate declines with age (RR ing, exposure to environmental toxic inhalants. max = 220-age). 3. Interventions to slow or reverse changes in car- e. Cardiac output decreases, 1% per year after age diopulmonary system . 20: due to decreased heart rate and stroke volume. f. Orthostatic hypotension: common problem in

a. Complete cardiopulmonary examination prior Geriatric Physical Therapy 261 to commencing an exercise program is essen- tial in older adults due the high incidence of d. Improve overall daily activity levels for inde- cardiopulmonary pathologies. pendent living. (1) Selection of appropriate exercise tolerance (1) Lack of exercise is an important risk factor testing protocol (ETT) is important. in the development of cardiopulmonary (2) Absence of standardized test batteries and diseases. norms for elderly. (2) Lack of exercise contributes to problems of (3) Many elderly cannot tolerate maximal test- immobility and disability in the elderly. ing; ubmaximal testing commonly used. (4) Testing and training modes should be similar. H. Integumentary System 1. Changes in skin composition. b. Individualized exercise prescription essential. a. Dermis thins with loss of elastin. (1) Choice of training program is based on: fit- b. Decreased vascularity; vascular fragility results ness level, presence or absence of cardio- in easy bruising (senile purpura). vascular disease, musculoskeletal limita- c. Decreased sebaceous activity and decline in tions, individual's goals and interests. hydration. (2) Prescriptive elements (frequency, intensity, d. Appearance: skin appears dry, wrinkled, yel- duration, mode) are the same as for lowed, and inelastic; aging spots appear (clus- younger adults. Refer to Chapter 3. ters of melanocyte pigmentation); increased (3) Walking, chair and floor exercises, modi- with exposure to sun. fied strength/flexibility calisthenics well- e. General thinning and graying of hair due to tolerated by most elderly. vascular insufficiency and decreased melanin (4) Con ider pool programs (exercises, walk- production. ing, swimming) with bone and joint f. Nails grow more slowly, become brittle and thick. impairments. 2. Loss of effectiveness as protective barrier. (5) Consider multiple modes of exercise (cir- a. Skin grows and heals more slowly, less able to cuit training) on alternate days to reduce resist injury and infection. likelihood of muscle injury, joint overuse, b. Inflammatory response is attenuated. pain, and fatigue. d. Decreased sensitivity to touch, perception of pain and temperature; increased risk for injury c. Aerobic training programs can significantly from concentrated pressures or excess temper- improve cardiopulmonary function in the elderly. atures. (1) Decreases heart rate at a given submaximal e. Decreased sweat production with loss of sweat power output. glands results in decreased temperature regula- (2) Improves maximal oxygen uptake (V02 tion and homeostasis. max). (3) Greater improvements in peripheral adap- I. Gastrointestinal System tation, muscle oxidative capacity then cen- 1. Decreased salivation, taste, and smell along with tral changes; major difference from train- inadequate chewing (tooth loss, poorly fitting den- ing effects in younger adults. tures), poor swallowing reflex may lead to poor (4) Improves recovery heart rates. dietary intake, nutritional deficiencies. (5) Decreases systolic blood pressure, may 2. Esophagus: reduced motility and control of lower produce a small decrease in diastolic blood esophageal sphincter; acid reflux and heartburn, pressure. hiatal hernia common. (6) Increase maximum ventilatory capacity: 3. Stomach: reduced motility, delayed gastric empty- vital capacity. ing; decreased digestive enzymes and hydrochlo- (7) Reduces breathlessness, lowers perceived ric acid; decreased digestion and absorption; indi- exertion. gestion common. (8) Psychological gains: improved sense of 4. Decreased intestinal motility; constipation common. well- being, self-image. (9) Improves functional capacity. J. Renal System 1. Kidneys: loss of mass and total weight with nephron atrophy, decreased renal blood flow, decreased filtration.

262 (5) High risk of fractures. (6) Trabecular bone more involved than corti- a. Blood urea rises. b. Decreased excretory and reabsorptive capacities. cal bone; common areas affected: 2. Bladder: muscle weakness; decreased capacity (a) Vertebral column. causing urinary frequency; difficulty with empty- (b) Femoral neck. ing causing increased retention. (c) Distal radius/wrist, humerus. a. Vrinary incontinence common (affects over 10 c. Examination. (1) Medical record review. million adults; over half of nursing home resi- (a) History, physical exam, nutritional his- dents and one third of community dwelling eId- ers); affects older women with pelvic floor tory. weakness and older men with bladder or (b) Bone density tests. prostate disease. (c) X-rays for known or suspected fractures. b. Increased likelihood of urinary tract infections. (2) Physical activity/fall history. (3) Assess dizziness: Dizziness Handicap III. Pathological Conditions Associated with Inventory. the Elderly (4) Sensory integrity: vision, hearing, somato- sensory, vestibular; sensory integration. A. Musculoskeletal Disorders and Diseases (5) Motor function: strength, endurance, motor 1. Osteoporosis: disease process that results in reduc- control. tion of bone mass; a failure of bone formation (6) ROM/flexibility. (osteoblast activity) to keep pace with bone reab- (7) Postural deformity. sorption and destruction (osteoclast activity). (a) Feet: hammer toes, bunions lead to a. Etiologic factors. (1) Hormonal deficiency: estrogens or andro- antalgic gait. gens. (b) Postural kyphosis, forward head posi- (2) Nutritional deficiency: inadequate calcium, impaired absorption of calcium; excessive tion. alcohol, caffeine consumption. (c) Hip and knee flexion contractures. (3) Decreased physical activity: inadequate (8) Postural hypotension. mechanical loading. (9) Gait and balance assessment. (4) Diseases that affect bone loss: hyperthy- d. Goals, outcomes, and interventions. roidism, diabetes, hyperparathyroidism, (I) Medications. rheumatoid arthritis, liver disease, Paget's (a) Evista. disease, certain types of cancer. (b) Fosamax (alendronate). (5) Medications that affect bone loss: corticos- (c) Calcitonin. teroids, thyroid hormone, anticonvulsants, (2) Promote health, provide counseling. catabolic drugs, some estrogen antagonists, (a) Daily calcium intake. chemotherapy. (6) Additional risk factors: family history, • 1000 mg premenopause. Caucasian!Asian race, early menopause, • 1500 mg after age 50 years of age. thin/small build, smoking. (b) Daily vitamin D intake. b. Characteristics. • 200 IV premenopause. (I) Affects about 20 million in U.S., 80% are • 400 IV after menopause. women; one-third will experience major • 600 IV after age 75. orthopedic problems related to osteoporosis. (c) Diet: low in salt, avoid excess protein: (2) Bone loss is about 1% per year (starting for inhibits body's ability to absorb calcium. women at ages 30-35, for men ages 50-55), (3) Maintain bone mass: exercise. accelerating loss in post-menopausal (a) Weight bearing (gravity-loading) exer- women, approximately 5% per year for 3- 5 cises: walking (30 min/day); stair- years. climbing; use of weight belts to (3) Structural weakening of bone. increase loading. (4) Decreased ability to support loads. (b) Resistance exercises, e.g., hip and knee extensors, triceps.

(4) Posturallbalance training. Geriatric Physical Therapy 263 (a) Po tural reeducation, postural exercises to reduce kypho is, forward head position. (2) Typically result from routine activity: (b) Flexibility exercises. bending, lifting, rising from chair. (c) Functional balance exercises, e.g., chair rises, standinglkitchen sink exercises (3) Chief complaints: immediate, severe local (e.g. toe raise, unilateral stance, hip spinal pain, increased with trunk flexion. extension, hip abduction, partial squats). (4) Lead to shortening of spine, progressive (d) Tai Chi. loss of height; spinal deformity (kyphosis), (e) Gait training. can progress to respiratory compromise. (5) Safety education/fall prevention. (5) Goals, outcomes, and interventions: acute (a) Proper shoes: thin soles, flat shoes phase. enhance balance abilities (no heels). (a) Horizontal bed rest, out of bed 10 min- (b) Assistive devices: cane; walker as utes every hour. needed. (b) Emphasis on proper posture, extension (c) Fracture prevention: counseling on in sleeping, sitting, and standing. safe activities; avoid sudden forceful (c) Isometric extension exercises in bed. movements, twisting, standing, bending over, lifting, supine sit-ups. (6) Goals, outcomes, and interventions: chronic phase. 2. Fractures. (a) Teach patient extension exercises; a. High risk of fractures in the elderly: associated avoid flexion activities. with low bone density and multiple risk factors, (b) Postural training. e.g., age, co-morbid diseases, dementia, psy- (c) Modalities for relief of pain. chotropic medications. (d) Safety education/modify environment. b. Hip fracture: common orthopedic problem of (e) Decrease vertebral loading, e.g., use older adult with more than 270,000 hip frac- soft soled shoes. ture annually in U.S.; rate doubles each decade after 50; by age 90 affects 32% of d. Stress fractures: fine, hairline fracture (insuffi- women and 17% of men. ciency fracture) without soft tis ue injury. (I) Mortality rate: 20%, associated with com- (1) In elderly, common in pelvis, proximal plications. tibia, distal fibula, metatarsal shafts, foot. (2) About 50% will not resume their premorbid (2) May be unsuspected source of pain. level of function, e.g., walk independently. (3) Observe for signs of local tenderness and (3) May result in dependency; continued insti- swelling, e.g., post exercise. tutionalization occurs in as many as 113 of (4) Goals, outcomes, and interventions. patients with hip fractures. (a) Rest. (4) Majority of hip fractures are treated surgi- (b) Correction of exercise excesses or cally: 95% are femoral neck or faulty exercise program. intertrochanteric fractures; remaining 5% (c) Reduction of vertical loading, e.g., oft are subtrochanteric fractures. sole shoes. (5) Intensive interdisciplinary rehabilitation program with early mobilization may e. Upper extremity fractures: humeral head, improve outcome. Colles' fractures common. (6) Treatment protocols are based on the type of fracture and surgical procedure used: inter- f. For discussion of fracture assessment and man- nal fixation versus prosthetic replacement. agement; Refer to Chapter 1. c. Vertebral compression fractures. (1) Usually occur in lower thoracic, lumbar g. Clinical implications of fracture management regions (T8-L3). in the elderly. (1) Fractures heal more slowly. (2) Older adults are prone to complications, e.g., pneumonia, decubiti, mental status complications with hospitalization. (3) Rehabilitation may be complicated or pro- longed by lack of support systems; co-morbid conditions, decreased vision, poor balance. 3. Degenerative arthritis (osteoarthritis): a non-

264 inflammatory, progressive disorder of joints, typi- B. Neurologic Disorders and Diseases cally affects hips, knees, fingers, and the spine. 1. Stroke (cerebrova cular accident, CVA): udden, a. Affects more than 16 million in U.S. focal neurologic deficit resulting from ischemic or hemorrhagic lesions in the brain. (1) Incidence increases with age: at age 55 a. Most common cause of adult disability in U.S. affects 57% of population; by age 75 (1) Incidence of stroke increases dramatically affects 70% of population. with age; most strokes (43%) occur in per- sons over the age of 74. (2) Prevalence higher in men up to age 45; by (2) Approximately 30 percent die during the age 65, women 5 times more likely to be acute phase and another 30-40 percent will affected. have severe disability. b. Clinical signs and symptom ; examination and b. Moderate to severe limitation in functional intervention: Refer to Chapter 2. daily activities seen in 24% of individuals. 2. Degenerative diseases. a. Parkinson's disease: chronic, progressive dis- c. Characteristics. ease of nervous system. (1) Pain, swelling, and stiffness, worse early (1) Parkinson's symptoms afflict about 20% of morning or with over-use, e.g., knee pain, individuals over the age of 65; frequency of hip pain. symptoms increases with age affecting (2) Muscle spasm. 50% of individuals over the age of 85. (3) Loss of range of motion and mobility; (2) Parkinson's disease affects about 1% of crepitus. individuals over age 55, reaching propor- (4) Bony deformity. tions of 2.6 percent by age 85; in U.S. (5) Muscle weakness secondary to disuse. affects approximately 1.5 million individu- als with 50,000 new cases annually; mean d. Goals, outcomes, and interventions. age of onset is between 59 and 62. (1) Medical management: nonsteroidal anti- (3) Clinical signs and symptoms; examination inflammatory drugs (NSAIDs), corticos- and intervention: Refer to Chapter 2. teroid injections, topical analgesics, joint 3. Clinical implications of neurological rehabilitation replacements. in the elderly. (2) Reduction of pain and muscle spasm: a. Older adults are prone to complications/indirect modalities, relaxation training. impairments, e.g., contracture and deformity, (3) Exercises. decubiti, mental status complications. (a) Maintain or improve ROM. b. Rehabilitation may be complicated or pro- (b) Correct muscle imbalances: strength- longed by lack of support systems, co-morbid ening exercises to support joints, conditions. decreased sensorimotor function., improve balance and ambulation. poor balance. (c) Aerobic conditioning: walking pro- c. With irrever ible neurologic disease, it is grams are associated with decreased important to address the impairments and func- joint symptoms, improved function, tional limitations respon ive to interventions; and sense of well-being.. overall focus should be on improved function (d) Aquatic programs, e.g., pool walking, and safety. Arthritis Foundation program: produces d. Compensatory treatment strategies should be beneficial effects similar to aerobic con- utilized when impairment cannot be remediat- ditioning; enhances ease of movement. ed; strategies can include environmental modi- (4) Patient education and empowerment. fications, assistive devices, use of home health (a) Teach patients about disease, taking an aides, etc. active role in care. (b) Teach joint protection, energy conser- C. Cognitive Disorders vation strategies. 1. Delirium: fluctuating attention state causing tem- (5) Provide assistive devices for ambulation porary confusion and loss of mental function; an and activities of daily living, e.g., canes, walkers, shoe inserts, reachers. (6) Promote healthy lifestyle: weight reduction to relieve stress on joints.

acute disorder, potentially reversible. (Table 8-1). Geriatric Physical Therapy 265 a. Etiology: drug toxicity and/or systemic illness, c. Primary degenerative dementia, Alzheimer's oxygen deprivation to brain; environmental type: (50-70% of dementias). changes and ensory deprivation, e.g., recent (1) Affects estimated 1.6 million individuals, hospitalization, institutionalization. 10-20% of the over 65 population; third b. Characteristics. costliest disease in U.S.; 4th leading cause (I) Acute onset, often at night; fluctuating of death. (2) Leading cause of institutionalization; affects course with lucid intervals; worse at night. up to 50% of nursing home population. (2) Duration: hours to weeks. (3) Etiology unknown. (3) May be hypo or hyper alert, distractible; (a) Evidence of chromosomal abnormalities. (b) Predisposing factors: family history, fluctuates over course of day. Down syndrome, traumatic brain (4) Orientation usually impaired. injury, aluminum toxicity. (5) lliusions/hallucinations, periods of agitation. (4) Pathophysiology. (6) Memory deficits: immediate and recent. (a) Generalized atrophy of brain with (7) Disorganized thinking, incoherent speech. decreased synthesis of neurotransmit- (8) Sleep/wake cycles always disrupted. ters, diffuse ventricular dilation. 2. Dementia: loss of intellectual functions and memo- (b) Histopathological changes: neurofib- ry causing dysfunction in daily living. (Table 8-1). rillary tangles; neuritic senile plaques: a. Criteria for dementia. build up of beta-amyloid protein. (1) Deterioration of intellectual functions: (5) Types. (a) Senile Dementia Alzheimer's Type impoverished thinking, impaired judgment; (SDAT): onset after the age of 60 disorientation, confusion; impaired social (average age 75). functioning. (b) Presenile Dementia Alzheimer's Type (2) Disturbances in higher cortical functions: (PDAT): onset between ages of 40-60. language (aphasia), motor skills (apraxia), (6) Characteristics. perception (agnosia). (a) Dementia: insidious onset with gener- (3) Memory impairment: recent and remote. ally progressive deteriorating course; (4) Per onality changes: alteration or accentu- irreversible, mean survival time post ation of premorbid traits; behavioral diagnosis is 4 years. changes. (b) May have periods of agitation and rest- (5) Alertness (consciousness) usually normal. lessness, wandering. (6) Sleep often fragmented. (c) Sundowning syndrome: confusion and b. Reversible dementias: (10-20% of dementias); agitation increases in late afternoon. multiple causes. (1) Drugs: sedatives, hypnotics, anti-anxiety d. Multi-infarct dementias (MID), (20-25% of agents, anti-depressants, antiarrhythmics, dementias). antihypertensives, anti-convulsants, anti- (1) Etiology: large and small vascular infarcts psychotics, drugs with anticholinergic side in both gray and white matter of brain, pro- effects. ducing loss of brain function. (2) Nutritional di orders: B-6 deficiency, thi- (2) Characteristics. amine deficiency, B-12 deficiency/perni- (a) Sudden onset rather than insidious; cious anemia, folate deficiency. stepwise progression. (3) Metabolic disorders: hyper/hypothy- (b) Spotty and patchy distribution of roidism, hypercalcemia, hyper/hypona- deficits: areas of preserved ability tremia, hypoglycemia, kidney or liver fail- along with impairments. ure, Cushing syndrome, Addison's disease, (c) Focal neurological signs and symp- hypopituitari m, carcinoma. toms, e.g., gait and balance abnormali- (4) Psychiatric disorders: depression, anxiety, ties, weakness, exaggerated DTRs. psychosis. (d) Emotional liability common. (5) Toxins: air pollution, alcohol.

266 ules, memory aids whenever possible. (e) Avoid stressful tasks, emphasize familiar, (e) Associated with history of stroke, car- diovascular disease, hypertension. well-learned skill ; provide redirection. (f) Approach learning in a simple, repeti- e. Other types of dementias. (1) Parkinson's disease: dementia estimated in tious way, proceed slowly, provide 10-35% of cases, in late stages of the disease. adequate rest time. (2) Alcohol-related: chronic alcoholism with (g) Provide mental stimulation: utilize prolonged nutritional (B 1) deficiency, e.g., simple, well-liked activities, games. Korsakoff's psychosis. (3) Provide regular physical activity. (a) Safe walking program. f. Examination. (b) Balance activities for fall prevention. (1) History: determine onset of symptoms, (c) Activities to promote body awareness progression, triggering events; common and sensory stimulation. problems, social history. (4) Participate in restraint reduction program. (2) Examine cognitive functions: orientation, (5) Educate/support family, caregivers. attention, calculation, recall, language. (6) Present a realistic, consistent team Standardized test: Mini-Mental State Exam approach to management. (MMSE); score of <24 out of possible 30 is 3. Depression: a disorder characterized by depressed indicative of mental decline/dementia. mood and lack of interest or pleasure in all activi- (3) Examine for impairments in higher cortical ties, and associated ymptoms for a period of at functions: inability to communicate, per- least two weeks. ceptual dysfunction. a. Incidence. (4) Examine for behavioral changes: restless, (1) Community-dwelling elderly: 5% have agitated, distracted, paranoid, wandering, clinically diagnosed major depression inappropriate social behaviors, repetitive (exhibit at least 5 symptoms); another 10- behaviors. 20% have depressive symptoms. (5) Examine self-care: ability to carry out (2) Institutionalized elderly: 12% have major activities of daily living, e.g., limitations in depression; another 15-20% have depressive grooming and hygiene, continence. symptoms. (6) Examine motor function: dyspraxia, gait b. Determine predisposing factors. and balance instability. (1) Family history, prior episodes of depression. (7) Examine environment for safety, optimal (2) Illness, drug side effects; hormonal. function. (3) Chronic condition: loss of phy ical func- tions, pain e.g., stroke. g. Goals, outcomes, and interventions. (4) Sensory deprivation Ooss of vision or hearing). (I) Environment. (5) History of losses: death of family and (a) Provide safe environment: prevent friends, job, income, independence. falls, injury or further dysfunction, (6) Social isolation: lack of family support. safety from wandering; utilize safety (7) Psychological losses: memory, intellectual monitoring devices as needed, e.g., functions. alarm device. c. Examine for depressive symptoms. (b) Provide soothing environment with (1) Nutritional problems: significant weight reduced environmental distractions: loss or weight gain; dehydration. reduces agitation, increases attention. (2) Sleep disturbances: insomnia or hypersomnia. (2) Support individual's remaining function. (3) Psychomotor changes: inactivity with (a) Approach the patient in a friendly, sup- resultant functional impairments, weakness portive manner; model calm behavior. or agitation. (b) Use consistent, simple commands; (4) Fatigue or loss of energy. speak slowly. (5) Feelings of worthlessness, low self-e teem, (c) Use nonverbal communication: senso- guilt. ry cues, gesture, demonstration. (d) Provide reorienting information: use prompts, e.g., wall calendars, daily sched-

(6) Inability to concentrate, slowed thinking, Geriatric Physical Therapy 267 impaired memory, indecisiveness. widely used. (7) Withdrawal from family and friends, self- (b) Psychotherapy. neglect. (c) Electroconvulsive shock therapy (8) Recurrent thoughts of death, suicidal (ECT) may be used if drug treatment is ideation; document and immediately report unsuccessful or contraindicated. all threats of suicide. (2) Avoid excessive cheerfulness; provide sup- port and encouragement. (9) Decline in cognitive function, i.e., docu- (3) Assist patient in adjustment process to loss- ment with Mini Mental State Exam. es, coping strategies. (4) Encourage activities, exercise program: (IO)Standardized test: Geriatric Depression aerobic training is associated with Scale; 30 item yes/no scale; score >8 indi- increased feelings of well-being. cates depression. (5) Assist in improving/maintaining independ- ence; emphasize mastery by patient, d. Goals, outcomes, and interventions. achievement of short-term goals rather than (1) Medical treatment. long-term goals. (a) Pharmacotherapy; tricyclic antidepres- sants (e.g., Chlorpromazine, Prozac) TABLE 8-1 - DIFFERENTIAL DIAGNOSIS: ORGANIC BRAIN SYNDROMES MULTI-INFARCT DEMENTIA SENILE DEMENTIA PRESENILE DEMENTIA ALZHEIMER'S TYPE (SDAT) ALZHEIMER'S TYPE (PDAT) Age of Onset 55-70 60+ 40-60 Gender Distribution M:W=2:3 Duration M:W =3:1 M:W =2:3 Mode of Onset varies: days>years varies: months>years; mean rapid Course survival 7-11 yr. mean survival 4 years Prognosis Outcome sudden gradual less gradual than SDAT Hereditary Precipitating Factors intermittent step-wise slowly or rapidly progressive rapidly progressive Neuropathology varies poor: mod. or severe cases very poor Clinical Signs of Brain death from CVA, CAD, or infection death from general system failure, infection Damage Impairment of Higher atherosclerosis multifactorial: age Cortical Functions some familial tendency genetic: chromosome 21 abnormality; APOE4 gene; traumatic brain injury, Down Syndrome Affect small or large areas of infarction neuronal degeneration, neurofibrillary tangles, amyloid deposits, senile Neuromuscular secondary gliosis, senile plaques not plaques, decreased cholinergic neuronal activity Seizures Medical common diffuse or focal, areas of preserved diffuse, generalized diffuse, generalized, more severe function than SDAT isolated impairments, focal signs, progressive dementia, progressive disorientation, memory loss, impaired episodes of confusion with lucid cognition, judgment, abstract thinking, visuospatial deficits, apraxia, intervals, some insight delusions, hallucinations; late stages: disorders of sleep, eating, sexual behavior, no insight emotional lability, anxious, depressed variable: depressed anxious, paranoid, hostile, restlessness, agitation, wandering, \"sundowning\" late: apathy personality changes: egocentricity, impulsivity, irritability, inappropriate social behaviors focal signs: may see hemiparesis, occasional tremors, generalized weakness, unsteady gait, increased hemisensory loss tone: rigid postures, decreased postural reflexes, increased fall risk, repetitive behaviors yes rare occasional TIAs, CVA, hypertension, headaches infections, contractu res, fractures, decubitus ulcers, urinary and fecal incontinence

268 b. Clinical signs and symptoms; examination and intervention. Refer to Chapter 5. D. Cardiovascular Disorders and Diseases 1. Hypertension: significant risk factor in cardiovas- G. Metabolic Pathologies cular disease, stroke, renal failure, and death. 1. Diabetes mellitus. 2. Coronary artery disease (CAD): affects 40% of a. Aging is associated with deteriorating glucose individuals aged 65-74 and 50% over age 75. tolerance; type II diabetes affects as many as a. Angina. 10-20% of individuals over age of 60. (1) Angina pain not always a consistent indica- b. Associated with obesity, and sedentary tor of ischemia in elderly; shortness of lifestyle. breath, ECG ST segment depression may c. Clinical signs and symptoms; examination and be more reliable indicators. intervention. Refer to Chapter 6. b. Acute myocardial infarction. (1) Clinical presentation may vary from IV. Patient Care Concepts younger adults: may present with sudden dyspnea, acute confusion, syncope. A. General Principles of Geriatric Rehabilitation (2) Clinical course often more complicated in 1. Recognize variability of older adults. the elderly, mortality rates twice that of a. Uniqueness of the individual. younger adults. b. Developmental issues unique to the elderly. c. Congestive heart failure. 2. Focus on careful and accurate clinical examination d. Conduction system diseases: pacemaker dys- to identify remediable problems. function results in low cardiac output. a. Determine capacity for safe function. 3. Peripheral vascular disease. b. Determine effects of inactivity versus activity. 4. Clinical signs and symptoms; examination and c. Determine effects of normal aging versus dis- intervention. Refer to Chapter 3. ease pathologies. 3. Focus on functional goals. E. Pulmonary Disorders and Diseases a. Determine priorities, remediable problems. 1. Chronic bronchitis. b. Develop goals, plan of care in conjunction with 2. Chronic obstructive pulmonary disease (COPD). patient/caregiver. 3. Asthma. 4. Promote optimal health. 4. Pneumonia. a. Focus on increasing health conducive behav- a. Initial symptoms may vary: instead of high iors, prevention of disability. fever, productive cough may see altered mental b. Minimize and compensate for health-related status, tachypnea, dehydration. losses and impairments of aging. 5. Lung cancer. 5. Restore/maintain individual's highest level of 6. Clinical signs and symptoms; examination and function and independence within the care envi- intervention. Refer to Chapter 4. ronment. a. Determine how patient autonomy can be maxi- F. Integumentary Disorders and Diseases mized by appropriate assistance and environ- 1. Pressure ulcers (decubitus ulcers). mental manipulations. a. Characteristics. b. Empower elders: ensure they are in control of (1) Affects 10 to 25 % of hospitalized, ill eld- their own decisions whenever possible. erly patients. c. Be sensitive to cultural and ethnicity issues; (2) Risk factors: immobility and inactivity, losses, fears and insecurities; provide comfort sensory impairment, cognitive deficits, and sustenance. decreased circulation, poor nutritional status, d. Enhance coping skills. incontinence and moisture. e. Recognize functional abilities, limitations of (3) Common over bony prominences: ischial caregivers. tuberosities, sacrum, greater trochanter, 6. Holism: consider the whole patient, integrate all heels, ankles, elbows and scapulae. facets of an individual's life. (4) If not treated promptly, can progress to a. Determine social support systems, effects of damage of deep structures. social isolation. (5) Potentially fatal in frail elderly and chroni- cally ill.

b. Determine effects of losses. Geriatric Physical Therapy 269 c. Determine effects of depression, dementia. 7. Recognize demands for continuity of care, interac- (d) Require physician recertification every tions in a complex health care delivery system. 30 days. a. Advocate for needed services. b. Provide effective documentation. (2) Private insurance requirements: vary by B. Reimbursement Issues specific carrier; most adopt Medicare 1. Benefits from government programs: cover about requirements. two-thirds (63%) of health care expenditures of older persons. b. Baseline data must be described in functional a. Medicare: federal government sponsored insur- and measurable terms. ance for persons over 65, disabled persons of c. Goals and outcomes should be measurable, all ages. objective, specific to patient, and indicate a (1) Part A covers inpatient hospital care, predicted time frame. skilled nursing facility care, home health d. Plan of Care (POC). care provided by agencies, hospice care. (1) Address findings, relate impairments to (a) No premiums; eligibility under social functional performance. (2) Include frequency and duration of treat- security. ment, projected end date and disposition. (b) Must pay deductibles and coinsurance. (3) Be certified by physician. (2) P~ B covers doctors services, outpatient services, durable medical equipment. e. Progress notes. (a) Must pay premiums to be eligible. (1) Focus on improvements, objective changes; (b) Must pay deductibles and coinsurance. subjective statements by patient. b. Medicaid (federal-state funding): covers (2) Document remaining deficits, lack of longterm care of frail and aged patients in nurs- progress, or declining status. ing homes; impoverished adults and children. (1) Must spend down/exhaust income to qualify C. Ethical and Legal Issues for low-income status. 1. Professional practice affirms patient rights and (2) Administered by individual states that set dignity (professional ethical standards, APTA qualification guidelines; specific require- Code of Ethics). ments vary by state. 2. Informed consent. 2. Supplemental insurance may be purchased from a. Respect for personal autonomy; competent private insurance companies. patients have the right to refuse treatment, e.g., a. Copayments that elderly must pay under do not resuscitate (DNR) orders. Medicare (Medex), termed Medigap policies. b. Legal right to self-determination. Information b. Long-term care insurance. must be provided to patient that outlines: c. Enrollment in Health Maintenance Organi- (1) The nature and purpose oftreatment. zations (HMOs). (2) Treatment alternatives. 3. Documentation and reimbursement. (3) Risks and consequences of treatment. a. Requirements specific to type of insurance pro- (4) Likelihood of success or failure of treatment. gram. c. Consent must be obtained from a legal guardian (1) Medicare requirements for physical therapy if the individual is judged incompetent. services. (1) Older adults with fluctuating mental abili- (a) Be prescribed by a physician. ties must be carefully evaluated for periods (b) Include a determination of need: must of lucidity. (2) Documentation with a mental status exam be reasonable and necessary for indi- is essential. vidual's illness or injury according to 3. Advance Care Medical Directive (Living Will) acceptable standards of practice. established by federal Patient Self-Determination (c) Require the skilled services of a Act of 1990. licensed physical therapist. a. Health Care Proxy (Durable Power of Attorney): identifies a valid agent who is grant- ed the authority to make health care decisions for an individual should that individual become incapacitated.

270 B. Falls and Instability 1. Falls and fall injury are a major public health con b. Requirements. cern for the elderly. (1) Regulated by individual states; specific a. Each year approximately 30 percent of person: requirements vary by state. over the age of 65 fall. (2) Must be in writing, signed by principal, b. 24 percent of falls result in severe soft tissue witnessed by two adults. injury and fractures. (3) Empowers health care agent: includes spe- (1) Mortality rate associated with falls is 6 per cific guidelines as to which treatment cent. options will be allowed, which will not, e.g., (2) Falls are a factor in 40 percent of admis artificial life support, feeding tubes, etc. sions to nursing homes. (4) Defines conditions/scope of agent's authority. c. Fall results. (l) Increased caution and fear of falling. V. Common Problem Areas for Geriatric (2) Loss of confidence to function independ ently. Clients (3) Reduced motivation and levels of activity. (4) Increased risk of recurrent falls. A. Immobility-Disability 2. Fall etiology: most falls are multifactorial, thl 1. Impaired mobility and disability can result from a result of multiple intrinsic and extrinsic factor host of diseases and problems. and their cumulative effects on mobility, e.g., dis 2. Limitations in function increase with age; in per- ease states, age-related changes. sons over 65. a. Intrinsic/physiological factors. a. 23% report difficulty with one or more personal (1) Age: incidence of falls increases with age. care activities. (2) Sensory changes. b. 27% report difficulty with one or more home (a) Reduced vision, hearing, cutaneou management activities. proprioceptive, and vestibular function 3. Immobility can result in additional problems. (b) Altered sensory organization for bal a. Immobility can lead to complications in almost ance, reduced resolution of sensory con every major organ system, e.g., pressure sores, f1ict situations, increased dependence 01 contractures, bone loss, muscular atrophy, support surface somatosensory inputs. deconditioning, etc. (3) Musculoskeletal changes. b. Metabolic changes can include: negative nitro- (a) Weakness. gen and calcium balance, impaired glucose tol- (b) Decreased range of motion. erance, decreased plasma volume, altered drug (c) Altered postural synergies. pharmacokinetics. (4) Neuromotor changes. c. Psychological changes can include loss of pos- (a) Dizziness, vertigo common. itive self-image, depression. (b) Timing and control problems: impairel d. Behavioral changes can include confusion, reaction and movement times; slowe, dementia secondary to sensory deprivation, onset. egocentricity. (5) Cardiovascular changes. e. Loss of independence and dependency. (a) Orthostatic hypotension. 4. Examination to identify the source of immobility (b) Hyperventilation, coughing, arrhythmi~ or disability. (6) Drugs. 5. Goals, outcomes, interventions. (a) Strong evidence linking psychotropi a. Establish a supportive relationship and promote agents. self-determination of goals. (b) Some evidence linking certain cardic b. Focus on optimal function, gradual progression vascular agents, especially those th~ of physical daily activities. cause peripheral vasodilation. c. Prevent further complications or injury. (c) Conflicting evidence linking ana] d. A team approach of health professionals to gesics, hypoglycemics. address all aspects of the patient's problems; patient participation in decision making.

b. Intrinsic/psychosocial factors. Geriatric Physical Therapy 271 (1) Mental status/cognitive impairment. (2) Depre sion. falls; with scores between 54-46, a 1 - (3) Denial of aging. point drop is associated with a 6-8% (4) Fear of falling: associated with self- increase in fall risk. imposed activity restriction. (c) Get Up and Go Test, GUG (Mathias, (5) Relocation. Nayak & Isaacs): assesses functional balance during rise from a chair, walk c. Extrinsic/environmental factors. 3 meters, turn, and return to chair; per- (1) Setting: three times as many falls for insti- formance scored with 5 point scale. tutionalized or hospitalized elderly than for Patients who score 3 or higher are at community dwelling. increased risk. (2) Consider ground surfaces, lighting, doors/ (d) Timed GUG (Podsiadlo): performance doorways, stairs. on the GUG is timed. Normal intact (3) At home, most falls occur in bedroom adults can perform the test in 10 sec- (42%); bathroom (34%). onds or less; 11-20 seconds is consid- ered within normal limits for frail eld- d. Activity-related risk factors. erly or disabled patients; patients who (1) Most falls occur during normal daily activ- take more than 20 seconds are at ity: getting up from bed/chair, turning increased risk for falls while patients head/body, bending, walking, climbing/- taken more than 30 seconds are at high descending stairs. risk. (2) Only a small percent (5%) occur during (e) Functional Reach, FR (Duncan): clearly hazardous activities, e.g., climbing assesses maximal distance a person on ladder. can reach forward beyond arm's length (3) Improper use of assistive device: e.g., while maintaining a fixed position in walker, cane, wheelchair. standing (single item test). Functional reach norms: adults 41-69 (men 14.9 ± 3. Fall Prevention. 2.2, women 13.8 ± 2.2); adults 70-87 a. Examination. (men 13.2 ± 1.6; women 10.5 ± 3.5). A (1) Accurate fall history: location, activity, FR of less than 10 is indicative of time, symptoms; previous falls. increased fall risk. (2) Physical examination of patient: cognitive, (f) Dynamic Gait Index (Shumway-Cook): ensory, neuromuscular, cardiopulmonary. assesses dynamic gait (8 items) includ- (3) Standardized tests and measures for func- ing changes in gait speed, head turns, tional balance and instability. pivot turns, obstacles and stairs. (a) Performance-Oriented Mobility Assess- Normal intact adults received a score ment, POMA I (Tinetti); assesses bal- of 21 ± 3; patients with history of falls ance (balance subtest, 9 items) and received a mean score of 11 ± 4. walking (gait subtest, 8 items). (g) Falls Efficacy Scale (Tinetti): assesses Maximum score is 28; patients who functional performance in 10 common score less than 19 are at high risk for activities and extensive fear of falling falls; scores between 19-24 are at mod- contributes to functional decline. erate risk. b. Identify fall risk: determine all intrinsic and/or (b) The Balance Scale (Berg): assesses extrinsic factors. functional balance (14 items) including c. Goals, outcomes, and interventions. maintenance of po ition (sitting, stand- (1) Eliminate or minimize all fall risk factors; ing), and postural adjustment to volun- stabilize disease states, medications. tary movements (e.g., sitting to stand- (2) Exercise to increase strength, flexibility. ing, standing to sitting, transfers, (3) Sensory compensation strategies. reaching forward> floor, stepping up). (4) Balance and gait training. Maximum score is 56; patients who (5) Functional training. score less than 36 are at high risk for

272 (b) Adverse effects are potentially dis- abling or life-threatening. (a) Focus on sit-to-stand transitions, turn- ing, walking, stairs. (2) High incidence of fall /hip fractures, e.g., psychotropic agents. (b) Modify activities of daily living for safety; provide assistive devices, adap- (3) Motor vehicle accidents. tive equipment as appropriate. 2. Older adults are at increa ed ri k for drug toxicity. (c) Allow adequate time for activities; a. Factors include age-related changes in pharma- instruct in gradual position changes. cokinetics. (1) Alterations in drug ab orption, distribution (6) Safety education. to tissues, oxidative metabolism. (a) Identify risks. (2) Alterations in excretion associated with a (b) Provide instructions in writing. decline in hepatic and renal function: (c) Communicate with family and care- decreased clearance in certain drugs, e.g., givers. digoxin, lithium. (3) Altered sensitivity to the effects of drugs. (7) Modify environment to reduce falls and (a) Increased with certain drugs, e.g., nar- instability: use environmental checklist. cotic analgesics, benzodiazepines. (a) Ensure adequate lighting. (b) Decreased with certain drugs, e.g., (b) Use contrasting colors to delineate drugs mediated by beta-adrenergic hazardous areas. receptors, isoproterenol, propranolol. (c) Simplify environment, reduce clutter. (4) Drugs may interfere with brain function, cause confusion, e.g., psychoactive drugs: d. When the patient falls. sedatives, hypnotics, antidepressants, anti- (1) Check for fall injury. convulsants, antiparkinsonism agents. (a) Hip fracture: complaints of pain in hip (5) Older adults have less homeo tatic reserve, especially on palpation; external rota- e.g., more susceptible to orthostatic hypoten- tion of leg; inability to bear weight on sion with vasodilating drugs due to damp- leg changes in gait, weight bearing. ened compensatory baroreceptor response. (b) Head injury: loss of consciousness, (6) Drug processing effects: multiple drugs mental confusion. compete for binding sites. (c) Stroke, spinal cord injury: loss of sen- (a) Drug to drug interactions, e.g., sation or voluntary movement. Levodopa and MAOI (monamine oxi- (d) Cuts, bruises, painful swelling. dase inhibitors) may result in hyperten- (2) Check for dizziness that may have preced- sive response. ed the fall. (b) Most drugs exert more than one specif- (3) Provide reassurance. ic action in the body (polypharmaco- (4) Do not attempt to lift patient by yourself, logic effects), e.g., prednisone pre- get help, provide first aid, call emergency scribed for anti-inflammatory action services if necessary. may benefit arthritic symptoms but (5) Solicit witnesses of fall event. will aggravate a coexisting diabetic state (augments blood glucose levels). C. Medication Errors 1. Scope of the problem. b. Physicians may prescribe inappropriate med- a. Most elderly (60-85%) utilize prescnptlOn ications for elderly; estimated in 17.5 percent drugs to address a chronic medical problem. of Medicare prescription . b. One-third have three or more medical problems requiring multiple medications and complex c. Most patients are not knowledgeable about dosage schedules. drug actions, drug side effects. c. Average older person takes between 4 and 7 prescription drugs each day; also takes an addi- d. Drug-food interactions can interfere with effec- tional 3 over-the-counter drugs. tiveness of medications, e.g., efficacy of d. Adverse drug reactions. Levodopa is compromised if ingested too soon (1) 4-10% of hospital admissions in the elderly. before or after a high protein meal; potential (a) Affects approximately 25% of all hos- pitalized patients over the age of 80.

vitamin/drug interactions. Geriatric Physical Therapy 273 e. Polypharmacy phenomena: multiple drug pre- diazepines, antipsychotic drugs, anticholin- scriptions. ergic drugs. (1) Exacerbated by elderly who visit multiple 3. Goals, outcomes, and interventions. a. Assist in adequate monitoring of drug therapy. physicians, use different pharmacies. (1) Recognize drug-related side effects, (2) Lack integrated care, e.g., computerized adverse reactions to drugs, potential drug interactions in the elderly. system of drug monitoring. (2) Carefully document patient responses to f. Health status influences/socioeconomic factors. medications, exercise and activity. b. Assist in patient and family drug education/ (1) Older adult have a high rate of medication compliance: e.g., understanding of purpose of dosage errors; associated with memory drugs, dosage, potential side effects. impairment, visual impairments, incoordi- c. Encourage centralization of medications nation, low literacy. through one pharmacy. d. Assist in simplification of drug regime and (2) Older adults are targeted for aggressive instructions. marketing by drug companies: may result (1) Admirlistration of drugs, e.g., daily pill box, in self-administration of medications for drug calendar. uninvestigated symptoms. (2) Check to see if patient is taking medica- tions on schedule. (3) Financial issues: due to high costs, fixed (3) Tune doses in conjunction with daily routine. incomes, elderly may skip dosages, stop e. Coordinate physical therapy with drug schedule/ taking medications. optimal dose e.g., exerci e during peak dose with individual on Parkinson's medications g. Common adverse effects. (Levodopa). (1) Confusion/dementia: e.g., tranquilizers, bar- f. Recognize potentially harmful interaction biturates, digitalis, antihypertensives, anti- effects: modalities that cause vasodilatation in cholinergic drugs; analgesics, antiparkin- combination with vasodilating drugs. sonians, diuretics, beta-blockers. D. Nutritional Deficiency (2) Sedation/immobility: e.g., psychotropic 1. Many older adults have primary nutritional prob- drugs, narcotic analgesics. lems. (3) Weakness: e.g., antihypertensives, vasodila- a. Nutritional problems in elderly are linked to tor, digitalis, diuretics, oral hypoglycemics. health status and poverty rather than to age (4) Po tural hypotension: e.g., antihyperten- itself. sives, diuretics, tricyclic antidepressants, (I) Chronic diseases alter the overall needs for tranquilizers, nitrates, narcotic analgesics. nutrients/energy demands, the abilities to (5) Depression: e.g., antihypertensives, anti- take in and utilize nutrients, and overall inflammatory, antimycobacterial, anti- activity levels, e.g., Alzheimer's disease, parkinsonians, diuretics, H2 receptor antag- CVA, diabetes. onists, sedative-hypnotics, vasodilators. (2) Limited, fixed incomes severely limit food (6) Drug induced movement disorders. choices and availability. (a) Dyskinesias (involuntary, stereotypic b. Both undernourishment and obesity exist in the and repetitive movements, i.e., lip elderly and contribute to decreased levels of smacking, hand movements, etc.) asso- vitality and fitness. ciated with long-term use of neuroleptic c. Contributing factors to poor dietary intake. drugs and anticholinergic drugs, (1) Decreased sense of taste and smell. Levodopa. (2) Poor teeth or poorly fitting dentures. (b) Akathisia (motor restlessness) associ- (3) Reduced gastrointestinal function. ated with antipsychotic drugs. (a) Decreased saliva. (c) E ential tremor associated with tri- (b) Gastromucosal atrophy. cyclic antidepressants, adrenergic (c) Reduced intestinal mobility; reflux. drugs. (d) Parkin onism: associated with antipsy- chotics, sympatholytics. (7) Incontinence: caused by or exacerbated by a variety of drugs, e.g., barbiturates, benzo-

274 (b) Nutritional educational programs. (c) Assistance in grocery shopping, meal (4) Loss of interest in foods. (5) Lack of social support, socialization during preparation, e.g., recommendations for home health aides. meals. (d) Elderly food programs: home deliv- (6) Lack of mobility. ered/ \"meals on wheels\"; congregate meals/ senior center daily meal pro- (a) Inability to get to grocery store, shop. grams; federal food stamp programs. (b) Inability to prepare foods. (2) Maintain physical function, adequate activity d. There is an age-related slowing in basal meta- levels. bolic rate and a decline in total caloric intake; most of the decline is associated with a concur- rent reduction in physical activity. e. Dehydration is common in the elderly, result- ing in fluid and electrolyte disturbances. (1) Thirst sensation is diminished. (2) May be physically unable to acquire/main- tain fluids. (3) Environmental heat stresses may be life threatening. f. Diets are often deficient in nutrients, especially vitamins A and C, B 12, thiamine, protein, iron, calcium/vitamin D, folic acid, zinc. g. Increased use of taste enhancers, e.g., salt and sugar, or alcohol influences nutritional intake. h. Drug/dietary interactions influence nutritional intake, e.g., reserpine, digoxin, antitumor agents, excessive use of antacids. 2. Examination. a. Dietary history: patterns of eating, types of foods. b. Psychosocial: mental status, desire to eat/depres- sion, social isolation. c. Body composition. (1) Weight/height measures. (2) Skin fold measurements: triceps/subscapu- lar skin fold thickness. (3) Upper arm circumference. d. Sensory function: taste and smell. e. Dental and periodontal disease, fit of dentures. f. Ability to feed self: mastication, swallowing, hand/mouth control, posture, physical weak- ness and fatigue. g. Integumentary: skin condition, edema. h. Compliance to special diets. i. Functional assessment: basic activities of daily living, feeding; overall exercise/activity levels. 3. Goal, outcomes, and interventions. a. Assist in monitoring adequate nutritional intake. b. Assist in health promotion. (1) Maintain adequate nutritional support. (a) Nutritional consults as necessary.

CHAPTER 9 THERAPEUTIC EXERCISE FOUNDATIONS Thomas Bianco and Susan O'Sullivan I. Strength Training (3) Susceptible to quick fatigue. d. Hereditary influences and fiber type distribu- A. Concepts of Muscle Function and Strength 1. Strength is the force output of a contracting mus- tion. cle and i directly related to the amount of tension (1) The percentage of either FT or ST fibers in a contracting muscle can produce. 2. Contractile elements of muscle. the body is determined by genetics. This a. Muscles are composed of fibers, which are ratio cannot be changed via normal exercise. made up of myofibrils. Myofibrils are com- (2) Specific training can modify metabolic posed of sarcomeres that are connected in characteristics of all fiber types; e.g., high- serie . The overlapping cross-bridges of actin intensity, anaerobic strength training will and myo in make up a sarcomere. stimulate optimal FT adaptation. b. When a muscle contracts, the actin-myosin fil- e. Order of fiber type recruitment. aments slide together and the muscle shortens. (1) Recruitment order depends upon type of The cross bridges slide apart when the muscle activity, force required, movement pattern, relaxes and returns to its resting length. and position of the body. 3. Motor unit nerve supply to the muscle. (2) ST motor units have the lowest functional a. Slow-twitch (ST) fibers (type I). thresholds and are recruited during lighter, (l) Slow contraction speed. slower efforts such as low-intensity, long- (2) Low force (tension) production. duration endurance activities. (3) Highly resistant to fatigue. (3) Higher forces with greater velocity cause b. Fast-twitch (FT) fibers (type ITa). the activation of more powerful, higher (1) Fast contraction speed. threshold FT motor units. (2) Fatigue resistant. (4) Order of recruitment is ST, followed by FT (3) Characteristics can be influenced by the ITa, and finally followed by FT IIb motor type of training. units. c. Fast-twitch (FT) fibers (type IIb). 4. Length-tension. (1) Fast contraction speed. a. As the muscle shortens or lengthens through (2) High force production. the available ROM the ten ion it produces varies. Maximum tension is generated at some

276 exercise. g. Cardiovascular status: reduction in resting midpoint in the ROM; less tension is developed in either shortened or lengthened ROM. blood pressure. b. The weight lifted or lowered cannot exceed h. Immunologic function. that which the muscle is able to control at its 3. Positive changes in function and quality of life. weakest point in the ROM. a. Improved balance and coordination. c. When a muscle is stretched beyond the resting b. Improved gait and functional mobility. length, there is a mechanical disruption of the c. Improved activities of daily living. cross-bridges as the microfilaments slide apart d. Improved job/recreational/athletic perform- and the sarcomeres lengthen. Releasing the stretch allows the sarcomeres to return to their ance. resting length. This change in ratio of length to e. Improved sense of well-being, posture and self tension is called elasticity. d. Once released, a muscle stretched into the elas- image. tic range will contract and produce a force or C. Guidelines to Develop Strength tension as the muscle returns to its original length. 1. Overload principle. To increase strength, the mus- B. Adaptations to Strength Training cle must be loaded or challenged beyond its cur- 1. Muscle. rent force capability. Higher levels of tension will a. Hypertrophy is an increase in muscle size as a cause hypertrophy and recruitment of muscle result of resistance training and can be fibers. This level will change with each adaptation. observed after at least 6-8 weeks of training. b. Remodeling: individual muscle fibers are 2. Specificity of training refers to adaptations in the enlarged, contain more actin and myosin and metabolic and physiologic systems of the body have more, larger myofibrils; sarcomeres are depending on the type of overload imposed. increased. Specific modes of exercise elicit specific adapta- c. An increase in motor unit recruitment and syn- tions creating specific training effects. chronization of firing facilitates contraction and maximizes force production. 3. Reversibility: benefits of training are not sustained d. The average person has a ratio of 50% fast to unless muscles are continuously challenged. slow-twitch motor units. Performing work- Detraining effects include decreased muscle loads of low intensity will challenge half of the recruitment and muscle fiber atrophy. body's muscle mass. High intensity exercises for shorter durations (less than 20 repetitions) 4. Metabolic effects of strength training. are needed to train the highly adaptable fast- a. Muscle contraction to about 60% of its force- twitch IIa fibers. generating capacity causes a blockage of blood e. Disuse atrophy occurs when a muscle loses flow to the working muscle. This is a result of both size and strength from lack of use or when increased intramuscular pressure. The energy a limb is immobilized. source for this level of muscle contraction is f. Cross-section area of a muscle highly corre- mainly anaerobic and does not improve with lates with strength gains. The larger the mus- aerobic conditioning. cle, the greater the strength of that muscle. b. Strength training of specific muscles has a brief 2. Positive changes in impairments. Improvement in: activation period and uses a relatively small a. Strength. muscle mass, producing less cardiovascular b. Bone mass. metabolic demands than vigorous walking, c. Body composition: fat to lean body composi- running, swimming, etc. tion. c. Rhythmic activities increase blood flow to d. Weight control and weight maintenance; exercising muscles via a contraction and relax- decreased risk of adult-onset diabetes. ation \"milking action\". The primary energy e. Reaction time. source is aerobic. f. Metabolism, calorie burning during and after d. Circuit training (cross training) with high repe- titions and low weights incorporate all modes of training and provide more general condi- tioning to improve body composition, muscu- lar strength and some cardiovascular fitness. 5. Common errors associated with resistance or

strength training. Therapeutic Exercise Foundations 277 a. Valsalva maneuver: forcible exhalation with are greater than the therapist can apply the glottis, nose, and mouth closed while con- manually. traction is being held. Valsalva increases b. Disadvantages. intrathoracic pressure, slows HR, decreases (1) Not easily modified to exercise in diagonal return of blood to the heart, increases venous or functional patterns. pre ure and cardiac work. (2) May not be safe if re istance needs to be b. Inadequate rest after vigorous exercise. Three carefully controlled or maintained at low to four minutes are needed to return the muscle levels. to 90-95% of pre-exercise capacity. Most rapid 3. Goals and indications for resi tance exercise. recovery occurs in the first minute. a. Increase strength as a mu cle group that lifts, c. Increasing exercise progression too quickly lowers, or controls heavy loads for relatively (intensity, duration, frequency) can overwork low number of repetitions. muscles and cause injuries. b. Increase muscular endurance by performing d. Substitute motions occur from too much resist- low-intensity repetitive exercise over a pro- ance, incorrect stabilization, and when muscles longed period of time. are weak from fatigue, paralysis or pain. c. Improve muscular performance related to D. Exercises to Improve Strength and Range strength and speed of movement. 1. Manual resistance is a type of active exercise in 4. Precautions. which another person provides resistance. a. Local muscle fatigue is a normal response of a. Advantages. the muscle from repeated dynamic or static (1) Useful in the early stages of an exercise contractions over a period of time. Fatigue is due to depleted energy store , insufficient oxy- program when the muscle is weak. The gen, and build-up of lactic acid. It i character- therapist can judge the capability of muscle ized by a decline in peak torque and increased to safely meet demands of exercise. muscle pain with occasional spasm and (2) Can be modified for a painful arc in the decreased AROM. joint range of motion. b. General muscular fatigue affects the whole (3) Safe resistance exercise when the joint body after prolonged activities such as walking movement needs to be carefully controlled or jogging; usually due to low blood sugar, and the resistance is mild to moderate. decreased glycogen stores in muscle and liver, (4) Can be easily changed to include diagonal depletion of potassium. or functional patterns of movement, (e.g. c. Fatigue may be associated with specific clini- PNF) or appropriate facilitation techniques cal diseases, e.g., multiple sclerosis, cardiac (e.g. quick stretch). disease, peripheral vascular dysfunction, and b. Disadvantages. pulmonary diseases. These patients fatigue (l) The amount of resistance cannot be meas- more rapidly and require longer rest periods. ured quantitatively. d. Overwork or overtraining causes temporary or (2) It may be difficult to maintain the same permanent loss of strength as a result of exer- resi tance during the full joint range of cise. In normal individuals, fatigue causes dis- motion and to consistently repeat the same comfort so overtraining and muscle weakness resistance. does not usually occur. Patients with lower (3) The amount of resistance is limited by the motor neuron disease who participate in vigor- strength of the therapist or caregiver. ous resistance exercise programs can have a 2. Mechanical re istance is a type of active exercise deterioration of strength, e.g., post-polio syn- in which resistance is applied through the use of drome. Overwork can be avoided with slow equipment or mechanical apparatus. progression of the exercise intensity, duration a. Advantages. and progression. (l) The amount of resistance can be measured e. Osteoporosis makes the bone unable to with- quantitatively and increased over time. stand normal stresses and highly susceptible to (2) Can be u ed when amounts of resistance pathological fracture. It may develop as a result

278 Nautilus or Cybex. These machines vary the resistance as the muscle goes through of prolonged immobilization, bed rest, the the ROM, providing resistance that the inability to bear weight on an extremity and as muscle can safely complete at various a result of nutritional or hormonal factors. points of the ROM. f. Acute muscle soreness develops during or (2) Free weights do not vary the resistance directly after strenuous anaerobic exercise per- through the ROM of a muscle. The weakest formed to the point of fatigue. Decreased blood point along the length-tension curve of flow and reduced oxygen (ischemia) creates a each muscle limits the amount of weight temporary build up of lactic acid and potassi- lifted. um. A cool-down period of low intensity exer- (3) Weight lifting machines are safer than free cise can facilitate the return of oxygen to the weights and used early in a resistance exer- muscle and reduce the soreness. cise or rehabilitation program. g. Delayed-onset muscle soreness (DaMS) can c. Isokinetic exercise is dynamic and has a speed begin 12 to 24 hours after vigorous exercise or control for muscle shortening and lengthening. muscular overexertion. It peaks 24 to 48 hours Resistance is accommodating and variable. after exercise. Muscle tenderness and stiffness (1) Peak torque, the maximum force generated can last up to 5 to 7 days. Usually it is greater through the ROM, is inversely related to after muscle lengthening or eccentric exercise. angular velocity, the speed the body seg- Severity of soreness can be lessened by gradu- ment moves through its ROM, e.g. increas- ally increasing intensity and duration of exer- ing angular velocity decreases peak torque cises. production. 5. Contraindications. (2) Concentric or eccentric resistance exercise a. Inflammation: resistance exercises can increase can be performed on isokinetic equipment. swelling and cause damage to muscles or (3) Isokinetic exercise provides maximum joints. resistance at all points in the ROM as the b. Pain: severe joint or muscle pain during exer- muscle contracts. cise or for more than 24 hours after exercise (4) During isokinetic testing, the weight of a requires an elimination or reduction of the body segment creates a torque output exercise. around the joint, e.g., the lower leg around 6. Types of resistance exercise. the knee joint in sitting knee flexion. This a. Isometric exercise is static and occurs when a gravity produced torque adds to the force muscle contracts without a length change. generated by the muscle when it contracts Resistance is variable and accommodating. and gives a higher torque output than is Contractions should be held for at least 6 sec- actually created by the muscle. The higher onds to obtain adaptive changes in the muscle. value can affect the testing values of the (1) Strengthening of muscles is developed at a muscle group and which muscle group needs to be strengthened. Software can cor- point in the ROM, not over the entire length rect for the effects of gravity. of the muscle. d. Eccentric (lengthening) versus concentric (2) This type of resistance exercise can (shortening). increase blood pressure and should be used (1) Maximum eccentric contraction produces cautiously with the patient with a cardiac more force than maximal concentric con- condition. traction. (3) Monitor for potential Valsalva maneuver. (2) Resistance training performed concentri- b. Isotonic exercise is dynamic and can have a cally improves concentric muscle strength constant (free weights) or a variable (machine) and eccentric training improves eccentric load as the muscle lengthens or shortens muscle strength (specificity of training). through the available ROM. Speed can be vari- (3) Eccentric contractions occur in a wide vari- able for this type of exercise. ety of functional activities such as lowering (1) Weight lifting machines have an oval shaped cam or wheel that mimics the length-tension curve of the muscle, e.g.,

Therapeutic Exercise Foundations 279 TABLE 9-1 - RESISTANCE TRAINING SPECIFICITY CHART RELATIVE OUTCOME % I RM REPETITION #OF SETS REST LOADING Muscular Endurance <70 RANGE 1-3 BETWEEN SETS Hypertrophy and Strength 70-80 1-6 Light Maximum Strength 12-20 1-5+ 20-30 seconds Moderate 80-100 8-12 30-120 seconds Heavy 1-8 2-5 minutes the body against gravity, e.g., sitting down tions are completed with brief rests (1-2 minutes) or descending stairs. between sets. Progression (DeLorme): exercise (4) Eccentric contractions provide a source of begins with 10 repetitions at 50% RM, followed shock absorption during closed-chain func- by 10 repetitions at 75% RM, and finally 10 repe- tional activities. titions at 100% RM. (5) Eccentric contractions consume less oxy- 2. Circuit weight training is a sequence of exercises gen and fewer energy stores than concen- for total-body conditioning. A rest period of usual- tric contractions against similar loads. ly 30 seconds to 1 minute is taken between each 7. Range of motion. exercise. Exercises can be done with free weights a. Short-arc exercise: resistance exercise per- or weight training machines. formed through a limited ROM, e.g., initial 3. Pylometric training or stretch-shortening activity exercise post knee surgery (ant. cruciate is an isotonic exercise that combines speed, re·pair), painful full range movement. strength, and functional activities. Used in later b. Full arc exercise: resistance exercise performed stages of rehabilitation to achieve high level of through full ROM. performance; e.g., jumping off of a platform then 8. Open vs. closed-chain exercises. up onto the platform at a rapid pace to improve a. Open-chain exercise occurs when the distal vertical jumping abilities. segment (hand or foot) moves freely in space; 4. Brief repetitive isometric exercise occurs with up e.g., when an arm lifts or lowers a hand held to 20 maximum contractions held for 5 to 6 sec- weight. onds and performed daily. A 20-second rest after b. Resistance exercises usually are open-chain, each contraction is recommended to prevent which may be the only option if weight bearing increases in blood pressure. Strength gain occur is contraindicated. in 6 weeks. c. Open-chain exercise does not adequately pre- pare a patient for functional weight bearing II. Endurance Training activities. d. Closed-chain exercise occurs when the body A. Training Strategies to Develop Muscular move over a fixed distal segment; e.g., stair Endurance climbing or squatting activities. 1. Muscular endurance is the ability of an isolated e. Closed-chain exercise loads muscles, bones, muscle group to perform repeated contractions joints and noncontractile soft tissues such as over time. ligaments, tendons, and joint capsules. 2. Muscular endurance is improved by performing f. Mechanoreceptors are stimulated by closed- low load resistance exercise for many repetitions. chain exercises adding to joint stability, bal- Exercise programs that increase strength also ance, coordination, and agility in functional increase muscular endurance. weight bearing postures. 3. Muscular endurance programs are indicated after E. Specific Exercise Regimens injuries to joints and soft tissues. Dynamic exer- 1. Progressive resistive exercise (PRE) uses the repe- cises at a high number of repetitions against light tition maximum (RM) or the greatest amount of resistance are more comfortable and create less weight a muscle can move through the range of joint irritation than heavy resistance exercises. motion a specific number of times (e.g., DeLorme 4. Early in a strength-training program, high repeti- used 10 RM as baseline). Three sets of 10 repeti- tions and low-load exercises cause less muscle soreness and reduce the risk of muscle injury.

280 function, e.g. maximum oxygen consump- tion (V02 max) or maximum heart rate B. Training Strategies to Develop Cardiovascular (HR max). Endurance (2) The V02 max or HR max can be measured 1. Cardiovascular endurance is the ability to perform directly or indirectly based on different large muscle dynamic exercise such as walking, methods; e.g., 3-minute step, 12-minute swimming, and/or biking, for long periods of time. run or I-mile walk test. 2. Overload principle is used to enhance physiologic (3) HR max can be estimated using 220 minus improvement and bring about a training change. the age of individual. Training level or tar- Specific exercise overload must be applied. get heart rate (THR) can be established at a. Training adaptation occurs by exercising at a 70% of maximum to increase aerobic level above normal. capacity. b. The appropriate overload for each person can (4) The Karvonen formula is used to predict be achieved by manipulating combinations of heart rate reserve (HRR) or HR max minus training frequency, intensity, and duration. the resting heart rate (RHR) and correlates 3. Specificity principle refers to adaptations in the directly to V02 max. THR = (HR max - metabolic and physiologic systems depending on RHR) x % of desired training intensity + the type of overload imposed. RHR. a. Specific exercise elicits specific adaptations (5) Rating of Perceived Exertion (RPE) can be creating specific training effects; e.g., swim used to evaluate training at submaximal training will increase cardiovascular condition- levels. A cardiorespiratory training effect ing only when tested in swimming. There is no can be achieved at a rating of \"somewhat crossover for conditioning from swimming to hard\" or \"hard\" (13 to 16 on the original running. Borg scale of 6 to 19). An appropriate level 4. Individual differences principle: training benefits of training should result in conversational are optimized when programs are planned to meet exercise or \"talk test\"; moderate exercise the individual needs and capacities of the partici- that is not too strenuous and can improve pants. endurance. 5. Reversibility principle: detraining occurs rapidly, c. Duration (time). after only 2 weeks, when a person stops exercis- (1) Duration is increased when intensity is lim- ing. Beneficial effects of exercise training are tran- ited, e.g., by initial fitness level. sient and reversible. Improvements in aerobic capacity therefore 6. FlIT equation: includes factors that affect train- depend on increasing exercise duration and ing; frequency, intensity, time and type. Intensity frequency, e.g,. 3-5 minutes per day pro- is interrelated with both duration (time) and fre- duces training effects in poorly conditioned quency. individuals whereas 20-30 minutes, 3-5 a. Frequency is the number of exercise sessions times per week is optimal for conditioned per week. If training at a lower intensity, then people. more frequent exercise is indicated. (2) Multiple sessions of short durations are (1) If the intensity is constant, the benefit from also indicated when intensity is limited by 2 versus 4 or 3 versus 5 times per week is environmental conditions, such as heat and the same. humidity or by medical conditions, such as (2) For weight loss, 5-7 days per week increas- intermittent claudication or congestive es the caloric expenditure more than 2 days heart failure. per week. (3) Obese individuals should exercise at longer (3) Less than 2 days per week does not pro- durations and lower intensities. At this duce adequate changes in aerobic capacity exercise level, the person can speak without or body composition. gasping and does not have muscle ache or b. Intensity (overload) is the primary way to burn from lactic acid accumulation. improve cardiovascular endurance. (4) Obesity increases the mechanical work of (I) Relative intensity for an individual is cal- culated as a percentage of the maximum

the heart and can lead to cardiac and left Therapeutic Exercise Foundations 281 ventricular dysfunction. d. Type of exercise needed to increase cardiovas- person to breathe through the nose can allow cular endurance should involve large muscle prolonged aerobic exercise to continue. groups activated in rhythmic aerobic nature. d. The problem is rare in activities that require Specificity of training should be considered. only short bursts of activity, such as baseball e. Refer to Chapter 3. and is more likely to occur in endurance activ- C. Training Strategies to Develop Pulmonary ities such as soccer. Endurance e. When exercising in humid versus dry environ- 1. Pulmonary endurance is related to the ventilation ments, the exercise-induced asthmatic response of the lungs and oxygen consumption. is considerably reduced. Refer to Chapter 4. 2. Ventilation is the process of air exchange in the D. Aerobic Training lungs. The volume of air breathed each minute or 1. Aerobic training (cardiorespiratory endurance minute ventilation (Ve) is 6 liters. Ve = breathing training) can result in higher fitness levels for rate x tidal volume. In maximum exercise, increas- healthy individuals, slow the decrease in function- es in breathing rate and depth may produce venti- al capacity in the elderly, and recondition those lation as high as 200 liters per minute. that have been ill or have chronic disease. 3. Energy is produced aerobically as oxygen is sup- 2. Positive effects of aerobic training on the cardio- plied to exercising muscles. Oxygen consumption vascular and respiratory systems. rises rapidly during the first minutes of exercise a. Improve breathing volumes and increased V02 then levels off as the aerobic metabolism supplies max. the energy required by the working muscles b. Increase heart weight and volume; cardiac (steady state). hypertrophy is normal with long-term aerobic 4. The more fit a person is, the more capable their training. respiratory system is of delivering oxygen to sus- c. Increase total hemoglobin and oxygen delivery tain aerobic energy production at increasingly capacity. higher levels of intensity. d. Decrease resting and submaximal exercise a. Obesity can impair pulmonary function heart rates. Can be utilized to measure because of the added effort to move the chest improvements from aerobic training. wall. e. Increase cardiac output and stroke volume. 5. In severe pulmonary disease, the cost of breathing f. Improve distribution of blood to working mus- can reach 40% of the total exercise oxygen con- cles and enhanced capacity of trained muscles sumption. This would decrease the oxygen avail- to extract and use oxygen. able to the exercising nonrespiratory muscles and g. Reduce resting blood pressure. limit exercise capabilities. Obesity can significantly 3. Continuous training at a submaximal energy increase the level of impairments. requirement can be prolonged for 20 to 60 minutes 6. Exercise induced asthma (EIA) can occur when without exhausting the oxygen transport system. the normal initial bronchodilatation is followed by a. Work rate is increased progressively as training bronchoconstriction. The reduction in airflow improvements are achieved; overload can be from airway obstruction affects the ability of the accomplished by inc'reasing the exercise dura- lungs to provide oxygen to exercising muscles. tion. a. EIA is an acute, reversible airway obstruction b. In healthy individuals, continuous training is that develops 5 to 15 minutes after strenuous the most effective way to improve endurance. exercise when a person does not breathe 4. Circuit training uses a series of exercise activities through the nose, which warms and humidifies that are repeated several times. the air. a. Several exercise modes can be utilized involv- b. When a person mouth breathes, the air is cold ing large and small muscle groups both stati- and dry, contributing to the bronchoconstric- cally and dynamically. tion. b. Circuit training improves endurance and c. Lowering the intensity level and allowing the strength by stressing the aerobic and anaerobic energy systems. 5. Interval training includes an exercise period fol-

282 potentially cause injuries. 3. Increasing intensity too fast can create a problem lowed by a prescribed rest interval. It is perceived to be less demanding than continuous training and for an individual during endurance training. tends to improve strength and power more than 4. Exercising at too intense a level can use the anaer- endurance. a. The relief interval can be passive or active; its obic energy system not aerobic system; this increases strength and power, not endurance. duration ranges from a few seconds to several 5. Insufficient warm-up or cool-down results in inad- minutes. Active or work recovery involves equate cardiorespiratory and muscular adaptation; doing the exercise at a reduced level. During there is inadequate time to prepare for or recover the relief period, a portion of the ATP and oxy- from higher intense activity. gen used by the muscles during the work peri- 6. Inconsistent training frequency, duration, or inten- od is replenished by the aerobic system. sity does not properly stress or overload the aero- b. The longer the work interval, the more the aer- bic system to create training effects. obic system is stressed and the duration of the F. Exercise at High Altitude rest period is not important. 1. At altitudes of 6,000 feet (2,000 m) or higher there c. In a short work interval, a work-recovery ratio can be a noticeable drop in performance of aerobic of 1: 1 to 1:5 is appropriate to stress the aerobic activities. system. A ratio of rest interval 1:lJ2 work inter- 2. The partial pressure of oxygen is reduced resulting val allows exercise to begin before recovery is in poor oxygenation of hemoglobin. complete. This stresses the aerobic system. 3. This hypoxia at altitude can result in immediate d. With appropriate spacing of work-relief inter- compensatory hyperventilation (stimulation of the vals, a significant amount of high-intensity baroreceptors) and increased heart rate. work can be achieved. The total amount of 4. Reduction in CO2 from hyperventilation results in work completed with interval training is more alkaline body fluids. greater than the amount of work accomplished 5. Adjustments or acclimatization to higher altitude. with continuous training. a. Takes 2 weeks at 2,300m and an additional 6. Warm-up and cool-down periods: each exercise session includes a 5-15 minute warm-up and a S- week for every additional 600m in altitude. IS minute cool-down period. b. There is a decrease in plasma volume (concen- a. The warm-up period prevents the heart and cir- culatory system from being suddenly taxed. It trating red blood cells) and an increase in total includes low intensity cardiorespiratory activi- red blood cells and hemoglobin improving ties and flexibility exercises. oxygenation. b. The cool-down period also consists of exercis- c. Changes in local circulation may facilitate oxy- ing at a lower intensity. It reduces abrupt phys- gen transport. iologic alterations that can occur with sudden d. Adjustments do not fully compensate for alti- cessation of strenuou exercise; e.g., venous tude. Max V02 is decreased 2% for every 300m pooling in the lower extremities which causes above 1,500m. Thus, there is a drop in per- decreased venous return to the heart. formance for endurance activities. c. Longer warm-up and cool-down periods may e. Training at altitude does not provide any be needed for deconditioned or older individu- improvement in sea-level performance. als. 6. The air in mountainou region tends to be cool E. Common Errors Associated with Muscular, and dry. Body fluids can be rapidly lost through Cardiovascular and Pulmonary Endurance evaporation and result in dehydration. Training a. Ensure adequate hydration for those exercising 1. Lack of exercise tolerance testing (ETT) before or engaged in sport at altitude. the exercise prescription is determined could result G. Exercise in Hot Weather in a training program set too high or too low for 1. When exercising in the heat, muscles require oxy- that particular individual. gen to produce energy. 2. Starting out at too high a level can overly stress the 2. To decrease metabolic heat, blood is hunted to the cardiorespiratory and muscular systems and periphery; thus, working muscles are deprived of needed oxygen.

3. Core temperature increases and sweating increas- Therapeutic Exercise Foundations 283 es. Fluids must be continually replaced or core temperatures can rise to dangerous levels. B. Stretching 1. Stretching involves any therapeutic technique that 4. Hot, humid environments diminish the evaporative lengthens shortened soft tissue structures and cooling component even with profuse sweating. increases ROM. Excess fluid loss can compromise cardiovascular 2. Type of stretching is determined by the type of function. force applied, the intensity of stretch, and duration of stretch to contractile and non-contractile tis- 5. Fluid replacement. sues. a. Maintain plasma volume. a. Manual passive stretching takes the structures b. Colder fluids are emptied from the stomach beyond the free ROM to elongate tissues more rapidly than room temperature fluids. beyond their resting length. c. Concentrated carbohydrate drinks impair gas- (1) The stretch force is applied for at least 15- tric emptying and slow fluid replacement. 30 seconds and repeated several times dur- d. Glucose-polymer drinks do not impair physio- ing a session. logic functioning. They may also resupply lost (2) Manual stretching is considered a short electrolytes. duration stretch, maintained statically for less time than mechanical stretching. 6. Repeated heat stress results in acclimatization in (3) Intensity and duration depend on patient about 10 days of exposure. tolerance and therapist strength and a. Exercise capacity is increased. endurance. b. Cardiac output is better regulated. (4) Low intensity manual stretch, applied as c. Sweating is more efficient. long as possible, is better tolerated and d. Acclimitization to heat stress does not serious- results in optimal improvement in tissue ly deteriorate with age. length with minimal risk of injury to any weakened tissue. 7. Men and women can adapt equally well to heat b. Ballistic stretching is a high-intensity very even though the mechanisms of thermoregulation short-duration \"bouncing\" stretch. By contract- differ slightly. The menstrual cycle is not a factor. ing the opposite muscle group, the patient uses body weight and momentum to elongate the 8. Obesity is a major consideration when exercising tight muscle. in the heat. (1) It is considered unsafe because of poor a. Excess fat slows conduction of heat to the control and the potential of rupturing weak- periphery. ened tissues. It should not be performed b. Excess fat increases the metabolic cost of after an injury or surgery. activity. (2) Ballistic stretch facilitates the stretch c. The addition of sports gear (e.g. football pads, reflex, causing an increase in tension in the helmets) coupled with a hot, humid environ- muscle that is being stretched. It is con- ment and activity can compromise thermoregu- traindicated in spastic muscles. lation in the obese with potentially fatal results. c. Prolonged mechanical stretching is a low- intensity external force (5 to 15 lb. to 10 per- III. Mobility and Flexibility Training cent of body weight) applied over a prolonged period by positioning a patient with weighted A. Flexibility pulley and traction systems. Dynamic splints or I. Flexibility refers to the ability to move a JOint serial casts may also be used. through an unrestricted, pain free range of motion (1) Prolonged stretch may be maintained for (ROM); the musculotendinous unit elongates as 20 to 30 minutes or as long as several the body segment moves through the ROM. hours. 2. Dynamic flexibility refers to the active ROM of a (2) Dynamic splints are applied for 8 to 10 joint and is dependent upon the amount of tissue hours to increase ROM. resistance met during active movement. (3) Low-intensity prolonged mechanical 3. Passive flexibility is the degree to which a joint can be passively moved through the available ROM and is dependent upon the extensibility of the muscle and connective tissue around the joint.

284 niques may be more painful especially if muscle co-contraction is present. stretching has been shown to be more 3. Contractile tissue. effective than manual passive stretching a. A muscle that i lengthened over a prolonged with long-standing flexion contractures. period of time will have an increa e in the num- d. Active stretching occurs when voluntary, unas- ber of sarcomeres in series. The mu cle will sisted movement by the patient provides the adjust its length over time. stretch force to a joint. It requires strength and b. A muscle immobilized in a shortened po ition muscular contraction of the prime mover to will have a decrease in the number of arcom- actively stretch the antagonist muscle group. eres and an increase in connective tissue. 0) The force is controlled by the patient and is c. The sarcomere adaptation is tran ient. A mu de considered low-intensity (to tolerance). allowed to resume its normal length will produce The risk of tissue injury is low. or absorb sarcomeres (lengthen or horten). (2) Duration is equal to passive manual stretch- 4. Neurophysiologic properties of contractile tissue. ing or about 15 to 30 econds and is limit- a. The muscle spindle monitors the velocity and ed by prime mover muscular endurance. length changes in muscle. e. Active inhibition (facilitated stretching) refers b. A quick stretch to a muscle stimulates the alpha to techniques in which the patient reflexively motoneurons and facilitates muscle contraction relaxes the muscle to be elongated prior to or via the mono ynaptic stretch reflex. This can during the stretching technique, e.g. proprio- increase tension in a mu cle to be lengthened. ceptive neuromuscular facilitation (PNF). c. The Golgi tendon organ (GTO) inhibits con- (1) Hold-Relax (HR): is a relaxation technique traction of the muscle. When exce ive tension usually performed at the point of limited develops, the GTO fire, inhibiting alpha ROM in the agonist pattern; an isometric motoneuron activity and decreasing tension in contraction of the range-limiting antagonist the muscle. is performed against slowly increasing d. Slow stretching especially applied at end range resistance, followed by voluntary relax- causes the GTO to fire and inhibit the mu cle ation, and passive movement by the thera- (autogenic inhibition), allowing the muscle to pist into the newly gained range of the ago- lengthen (stretch-protection reflex). nist pattern. The muscle relaxes as a result 5. Non-contractile connective tissue including liga- of autogenic inhibition possibly from the ments, tendons, joint capsules, fasciae and skin, Golgi tendon organ (GTO) firing and can affect joint flexibility and requires remodeling decreasing muscular tension. to increase length. (2) Hold-Relax-Active Contraction (HRAC): b. Low-magnitude loads over long periods following hold-relax technique, active con- increase the deformation of noncontractile tis- traction into the newly gained range of the sue, allowing a gradual rearrangement of colla- agonist pattern is performed. The muscle is gen bonds (remodeling). This type of stretch is further relaxed through the inhibitory better tolerated by the patient. effects of reciprocal inhibition. c. 15 to 20 minutes of low-inten ity su tained (3) Contract-Relax-Active Contraction (CRAC): stretch, repeated on 5 con ecutive days, can i a relaxation technique usually performed cause a change in the length of mu cle and at a point of limited ROM in the agonist connective tissue. pattern; isotonic movement in rotation is d. Intensive stretching is u ually not done every performed followed by an isometric hold of day in order to allow time for healing. Without the range-limiting muscles in the antago- healing time, a breakdown of tissue will occur, nist pattern against slowly increasing as in overuse syndromes and stress fractures. resistance, voluntary relaxation, and active e. With aging, collagen loses its elasticity and ti - movement into the new range of the agonist sue blood supply is decrea ed reducing healing pattern. capability. Stretching in older adults should be (4) Indications for active inhibition techniques performed cautiously. include limitations in ROM caused by mus- cle tightness or muscle spasm. CR tech-

6. Over tretch is a stretch well beyond the normal Therapeutic Exercise Foundations 285 joint ROM re ulting in hypermobility. If the sup- porting tructure of a joint are in ufficient and 3. Massage increases local circulation to the muscle weak, they cannot hold a joint in a stable, func- and reduces muscle spasm and stiffness. tional position during functional activities. This is known as tretch weakness. 4. Biofeedback helps the patient reduce the amount of tension in a muscle and improves flexibility 7. Contracture is the adaptive shortening of muscle while decreasing pain. Increased level of feedback or other soft tissues that cross a joint; contracture signals (auditory, visual) assists the patient in rec- results in decreased ROM. ognizing tense muscles. a. Myotatic contracture (pertaining to muscle) involve a musculotendinous unit that has D. Common Errors Associated with Mobility and adaptively shortened with loss of ROM. Flexibility Training Usually occurs without specific tissue patholo- 1. Passively forcing a joint beyond its normal ROM. gy and in two-joint muscles such as the ham- 2. Aggressively stretching a patient with a newly strings, rectus femoris or gastrocnemius. Can united fracture or osteoporosis may result in frac- typically be resolved in a short time with gen- ture. tle stretching exercises and active inhibition 3. Using high-intensity, short-duration stretching techniques. procedures on muscles and connective tissues that b. Adhesions can occur if tissue is immobilized in have been immobilized over a long time or recov- a shortened position for extended periods of ering from injury or surgery. time, resulting in a loss of mobility. 4. Stretching muscles around joints without using c. Scar tissue adhesions develop in response to strengthening exercises to develop an appropriate injury and the inflammatory response. Initially, balance between flexibility and strength. new fibers develop in a disorganized pattern and 5. Overstretching of weak muscles, especially postur- will restrict motion unles remodeled along al muscles that support the body against gravity. lines of stress, e.g., the patient with bums. d. Irreversible contracture is a permanent loss of IV. Postural Stability Training soft tissue extensibility that cannot be released by nonsurgical treatment. It occurs when nor- A. Stability (Static Postural Control) mal oft ti He is replaced by an excessive 1. Refers to the synergistic coordination of the neu- amount of non-extensible tissue such as bone romuscular system enabling an individual to main- or fibrotic tissue. tain a stable position in an antigravity, weight bearing position. C. Relaxation of Muscles 2. Stability control involves prolonged holding, an 1. Local relaxation techniques can assist in the length- endurance function. ening of contractile and noncontractile tissue. 2. Heat increases the extensibility of the shortened B. Dynamic Stabilization, Controlled Mobility tissues. Warm muscles relax and lengthen more 1. Proximal segments and trunk provide a stable base easily, reducing the discomfort of stretching. for functional movements. Connective tissue stretches with less force and a. An individual maintains postural stability of shorter duration. the trunk while weight shifting. a. The GTO sensitivity is increased which makes b. Distal segments are fixed while proximal seg- it more likely to fire and inhibit mu cle tension. ments are moving. b. Low-intensity active exerci e performed prior c. Movement normally occurs through incre- to tretching will increase circulation to soft ments of range (small range to large range). tissue and warm the tissues to be stretched. 2. Patients with hyperkinetic movement disorders c. Heat without stretching has little or no effect (e.g., ataxia) need to be progressed from large on long-term improvement in muscle flexibili- range to small range movements and finally to ty. The combination of heat and stretching pro- holding steady (stability control). duces greater long-term gains in tissue length than stretching alone. C. Dynamic Stabilization, Static-Dynamic Control 1. An individual maintains postural stability of the trunk during dynamic extremity movements (e.g., reaching, kicking a ball). 2. Strength, endurance, flexibility, and coordination are needed for static and dynamic stabilization.

286 nist patterns performed without relaxation using careful grading of resistance; results in D. Guidelines to Develop Postural Stability cocontraction of opposing muscle groups; RS 1. It is important to consider exercise protocols that emphasize rotational tability control. effectively challenge core muscle groups and cre- 8. During early training, empha ize muscles needed ate adequate stability to perform functional activi- for trunk support in the upright posture, for per- ties. Stability requires the recruitment of tonic, forming basic body mechanics, and for upper slow-twitch muscle fibers for sustained periods of extremity lifting. time. 9. Teach control of functional positions while mov- 2. Start training by teaching safe spinal ROM in a ing from one position to another. This i called variety of basic postures. Teach chin tucking with transitional stabilization and require graded con- axial extension of the cervical spine and pelvic tilt- tractions and adju tments between the trunk flex- ing with ROM of the lumbar spine. ors and extensors. Con ider moving out of a pos- 3. Incorporate procedures to retrain kinesthetic ture (eccentric control) before moving into a pos- awareness of postural position. Teach the neutral ture (concentric control). pelvis position first to ensure a stable base. 10. Introduce simple patterns of motion that develop a. Emphasis is placed on strength and endurance safe body mechanics and movement. of back multifidi and oblique abdominals II. Closed-chain tasks are good choices to enhance rather than erector spinae. postural stabilization, e.g., partial squats and con- b. Focus on patient awareness of normal align- trolled lunges; add arm motions and weights as ment of the spine and pelvis feel of the muscles tolerated. contracting to maintain that position while 12. More complex patterns of movement, e.g., rotation exercising. and diagonal motions, can be added, e.g., PNF c. Visual, verbal, and proprioceptive cues, e.g., trunk patterns of chop/rever e chop, or lift/reverse resistance of elastic bands or light manual lift. Postures can be progressed to add difficulty, resistance, can be used to improve postural e.g., supine to sitting to standing. awareness. 13. Incorporate stretching into the postural exercise pro- 4. To safely develop strength and endurance in the gram. Adequate flexibility is necessary for postural stabilizing muscles, practice maintained holding in muscles to hold body parts in proper alignment. a variety of postures. The higher the center-of- E. Common Errors Associated with Postural Stability mass and smaller the base-of-support, the greater Training the degree of postural challenge, e.g., sitting ver- 1. Inadequate stretching of tight mu cles, e.g., tight sus standing. hip flexors that hold the pelvi in an anterior pelvic 5. Movements of the extremities challenge the trunk tilt or tight hamstrings that hold the pelvis in a pos- and neck stabilization; functional position must be terior tilt; both prevent a stable postural base (neu- maintained as movements are carried out. tral pelvis and spine position). 6. Resistance can be applied to the trunk or to the 2. Inadequate control of core muscles could place moving extremities; functional position must be excessive stress on proximal structures during maintained as the resistance is increased. functional activities e.g., the vertebrae and discs of 7. Alternating isometric contractions between antag- the spine during sitting. onists can enhance stabilizing contractions and 3. Progressing too quickly or starting at too high a develop postural control, e.g., PNF techniques of functional level for the patient to maintain postur- Alternating Isometrics (AI) and Rhythmic al stability. Stabilization (RS). 4. Exercising past the point of fatigue, which i deter- a. Alternating Isometrics (AI): isometric holding mined by the inability of the trunk or neck mu cles is facilitated fust on one side of the joint, fol- to stabilize the spine in its functional position. lowed by alternate holding of the antagonist 5. Attempting to force a patient into a general neutral muscle groups. May be applied in a variety of position, instead of finding the proper and safe directions, i.e. anterior-posterior, medial-later- position for each individual. al, diagonal. b. Rhythmic Stabilization (RS): simultaneous iso- metric contractions of both agonist and antago-

F. Stability Ball Training (also known as Swiss Ball, Therapeutic Exercise Foundations 287 Physio ball, or Therapy Ball) 1. Benefits/uses. a. Ball should be comfortable and have some a. Promotes balance; provides an unstable base of bounce. support, requiring continuous adjustments in balance. Moving the feet and/or the ball b. A firm ball moves more quickly. changes the base of support and challenges bal- c. A soft ball moves more slowly, may make ance. Allows safe practice of falling. b. Works muscles in functional, synergistic pat- patient feel safer, more secure. terns. d. Surface affects movement of the ball: quicker (1) Recruits and retrains core muscles (deep spinal and abdominal muscles). on hard surface, slower on mat or soft surface. (2) Promotes postural relearning, e.g., neutral 5. Precautions. position in sitting, cervical or trunk rotation. (3) Enhances coordination, movement combi- a. Obese individuals, exceeding ball weight lim- nations: e.g., arm and leg bilateral symmet- its. rical, bilateral asymmetrical movements, four-limb Mexican hat dance. b. Avoid sharp belt buckles, zippers when over c. Heightens proprioception and sensory percep- the ball; check surface for sharp objects. tion, awareness of the body moving in space. d. Improves range of motion, allows safe stretch- c. Lack of foot traction, feet slipping: use bare ing, e.g., total body extension or flexion, upper feet, rubber-soled shoes, or yoga sticky mat. or lower extremity stretches. e. Allows relaxation training, e.g., gentle bounc- d. Requires adequate space around exercising ing combined with deep breathing. Gentle individual. rocking can be used to decrease tone in hyper- tonic patient. e. Watch for sensory overload: sympathetic signs f. Allows a safe, dynamic cardiovascular work- (e.g., children, adults with traumatic brain out, e.g., dynamic bouncing with extremity injury). movements. g. Increases strength. Can be combined with f. Increased pain with mobility exercises and resistance training, e.g., lifting the ball with degenerative joint disease. arms or legs; using hand weights or resistive bands while on ball, or closed chain exercises, g. Muscle fatigue. e.g., partial squats using the ball. 6. Contraindications. h. Has been used to replace chairs in schools; improves posture and concentration, calms a. Dizziness or nausea. hyperactive children. b. Extreme anxiety or fear of being on the ball. 2. Advantages: light, portable, durable, and inexpen- sive. v. Coordination and Balance Training 3. Determining appropriate ball size. a. Sitting on ball with feet flat, the ball height A. Goals and Outcomes should place the hips and knees at 90 degree I. Motor function (motor control and learning) is angles. improved. b. Supine with ball under knees, the ball height 2. Postural control, biomechanical alignment, and should equal the distance between the greater symmetrical weight distribution are improved. trochanter and the knee. 3. Strength, power, and endurance necessary for c. Quadruped, the ball height should equal the movement control and balance are improved. distance between the shoulder and the wrist. 4. Sensory control and integration of sensory systems 4. Firmness/inflation. (somatosensory, visual, and vestibular) necessary for movement control and balance are improved. 5. Performance, independence, and safety are improved in transfers, gait, and locomotion. 6. Performance, independence, and safety are improved in basic activities of daily living (BADL) and instrumental activities of daily living (IADL). 7. Aerobic capacity and endurance are improved. 8. Self-management of symptoms is improved. B. Training Strategies to Improve Coordination and Balance 1. Motor learning strategies are important to assist the CNS in adaptation for movement control. a. Learning requires repetition. Practice sched- ules should be carefully organized. Initial prac-

288 3. Compensatory strategies are utilized as appropri- ate to promote safety and early resumption of tice may feel threatening to patient, e.g., patient functional skills, e.g., the patient with delayed or may feel in danger of losing control or balance. absent recovery, multiple co-morbidities. Progression should be gradual; the therapist Compensatory training may lead to learned non- should ensure patient confidence and safety, use of impaired extremities and delay recovery in continuing motivation. those patients with recovery potential, e.g., the b. Sensory cues are used to enhance motor per- patient with stroke. formance. a. Safety is improved by substitution: intact seg- c. Feedback should stress knowledge of results ments (sound limbs) for impaired segments; (KR). Attention is drawn to the success of the cognitive control for impaired motor control, outcome. It is important to establish a reference e.g., the patient with ataxia. of correctness during early, cognitive learning. b. Safety is improved by altering postural strate- d. Feedback should address knowledge of per- gies, e.g., widening the base of support (BOS) formance (KP). Attention is drawn to missing and lowering the center of mass (COM). elements, how to recruit, correct responses, c. Safety is improved by use of appropriate assis- sequence responses. tive devices and shoes, e.g., weighted walker, e. Feedback schedules: feedback given frequently athletic shoe. (after every trial) improves initial performance. d. Safety is improved through environmental Feedback given less frequently (summed after adaptations, e.g., handrails, adequate lighting, a given number of trials or fading with decreas- and removal of throw rugs, contrast tape on ing frequency) improves retention of skills. stairs, etc. f. A variety of activities and environments should be used to promote adaptability and generaliz- C. Interventions to Improve Coordination ability of skills. Practice is from a closed envi- 1. Functional training. ronment (fixed) environment to open variable a. Initial focus is on postural stability activities: environments. holding. g. Patient decision making skills are promoted. (1) A number of different weight-bearing pos- 2. Remediation/facilitation approaches reduce the tures can be used, e.g., prone-on-elbows, effects of specific impairments; focus is on use of sitting, quadruped, kneeling, plantigrade, involved body segments (e.g., affected extremities and standing. Progression is to gradually in the patient with stroke). decrease BOS while raising height of a. Control is first developed in isolated move- COM. ments and progressed to more complex move- (2) Specific exercise techniques to enhance ments. Developmental postures/activities can stability include: alternating isometrics be used to isolate body segments and focus on (AI) and rhythmic stabilization (RS). specific body skills, e.g., weight shifts to (3) Use slow-reversal-hold (SRH) through improve hip control are practiced first in kneel- decreasing ROM with ataxic movements. ing before standing. b. Progress to controlled mobility activities: b. Control is first achieved in holding (stability) weight shifting through decrements (decreas- before moving in a posture (stability-dynamic ing) ROM progressing to stability (steady hold- control) and skill level function (e.g., gait). ing); moving in and out of postures (movement c. Specific techniques can be used to remediate transitions). impairments (weakness, incoordination, and (1) Specific exercise techniques include: slow adaptive shortening, abnormal tone); e.g., tap- reversals (SR), SRH, guided movements. ping to improve responses of a weak quadri- (2) PNF patterns can be utilized to enhance ceps in standing. synergistic control and reciprocal action of d. As quality of movement improves, speed of muscles; techniques of SR or SRH can be movement and control is increased. used to modulate timing and force output. e. Active responses and active learning should be c. Aquatic exercises: water increases propriocep- promoted; progression is to unassisted or un- tive loading, slows down ataxic movements, facilitated movements as soon as possible.

provides buoyancy and light resistance. Therapeutic Exercise Foundations 289 d. Stabilization devices, e.g., air splints, soft neck c. Gait activities: practice walking forwards, collars, stabilize body segments and eliminate backwards, sidewards; slow to fast; normal unwanted movement. BaS to narrowed BaS; wide turns to the right e. Environment: patients with ataxia do better in a and left; 3600 turns; head turns right and left; low stimulus environment; allows better uti- crossed-step walking and braiding; over and lization of cognitive strategies. around obstacles. 2. Sensory training. a. Patients with proprioceptive losses. d. Elevation activities: practice step-ups, lateral (1) Vi ual compensation strategies, e.g., step-ups, stair climbing, ramps. Frenkel's exercises in which position is e. Dual-task training. In standing or walking, varied from supine to sitting to standing; practice simultaneous DE activities (e.g., movements are guided visually. bouncing a ball, catching or throwing a ball); in (2) Light weights: wrist cuffs, ankle cuffs, standing, practice LE activities (e.g., kicking a weighted walkers, elastic resistance bands ball, tracing letters with one foot). to increase proprioceptive loading. b. Patients with visual losses benefit from cogni- f. Community activities. Practice walking in open tive training strategies along with environmen- (variable) environments; pushing or pulling tal adaptations and assistive devices. doors, car transfers, grocery shopping, etc. D. Interventions to Improve Balance 1. Exercises to improve ROM, strength, and syner- g. Practice anticipatory timing activities\" e.g., gistic responses in order to withstand challenges to getting on/off elevator, escalator. balance. Key activities include: a. \"Kitchen sink exercises\": heel-cord stretches, 3. Disturbed balance activities. heel-rise , toe-offs, partial wall squats, single- a. Therapist-initiated manual perturbations (sit- leg activities (side kicks, back kicks), marching ting, standing); carefully grade force of pertur- in place, look-arounds (head and tmnk rota- bations, range and speed of movements. tion), hip circles. Progression from bilateral b. Stability ball training. Practice sitting, active upper extremity (UE) touch-down support to weight shifts (e.g., pelvic clock), UE move- unHateral UE support to no UE support. ments (e.g., arm circles, reaching), LE move- b. Postural awareness training: focus on control ments (e.g., stepping, marching), trunk move- of body position, centering the center of mass ments (e.g., head and trunk turns). (COM) within the limits of stability (LOS). c. Wobble board/equilibrium boards. Practice c. Weight shifts (postural sway): training of ankle both self-initiated and therapist-initiated shifts strategies, hip strategies. Can include postural in sitting or standing. Gradually increase range way biofeedback (e.g. Balance Master). and speed of shifts. d. Training of change-of-support strategies: step- ping strategies (forwards, backwards, side- 4. Sensory training. wards, crossed-step); DE reaching and protec- a. Visual changes. Practice standing and walking tive extension. eyes open (EO) to eyes closed (EC); full light- 2. Functional training activities. ing to reduced lighting. a. Sit-to-stand (STS) and sit-down (SIT) activi- b. Somatosensory changes. Practice standing and ties. Practice moving body mass forward over walking on tile floor to carpet (low pile to BaS, extending LEs and raising body mass high); dense foam, outside terrain. over feet and reverse. Focus on balance control c. Vestibular changes. Practice standing and while pivoting body mass over feet. walking and moving head side-to-side, up-and- b. Floor-to-standing rises. Practice rising from down; on a moving surface (e.g., escalator, ele- floor to standing in the event of a fall: e.g., vator, bus). side-sit to quadruped to kneeling to half-kneel- d. Introduce sensory conflict situations (e.g., ing to standing transitions. standing on foam cushion with eyes closed). 5. Safety education/fall prevention. a. Assist patient in identification of fall risk fac- tors, e.g., effect of medications, postural hypotension. b. Lifestyle counseling: assist the patient in rec- ognizing unsafe activities, harmful effects of a

290 parried by techniques designed to promote relax- ation, improve circulation, and maintain flexibility. sedentary lifestyle. B. Training Strategies to Promote Relaxation c. Refer to section on Falls and Instability, 1. Start with the patient in a comfortable resting posi- tion with all body parts well supported. Chapter 8. 2. Jacobson's progressive relaxation technique E. Interventions to Improve Aerobic Capacity and includes a systematic distal to proximal progres- sion of conscious contraction and relaxation of Endurance musculature. 1. Treadmill walking: focus on velocity control; pro- a. A period of reflex relaxation follows active gression is from slow to fast. Safety harness can be contraction of muscle. The stronger the con- worn to provide partial body weight support traction, the greater the relaxation. (BWS) if patient is unstable, e.g., the patient with b. Breathing control: deep breathing is coupled ataxia or stroke. Incline and di tance can also be with the progressive relaxation to further pro- modified. mote relaxation. In diaphragmatic breathing, 2. Ergometers. Pace pedaling on a cycle ergometer; the patient breathes in slowly and deeply progression is from slow to fast. Resistance and through the nose, allowing the abdomen to distance can also be modified. Can include both relax and expand, then relaxes and allows the LE and UE training. air to be expired through the relaxed open 3. Strength training. mouth. a. Active/active assistive exercise. 3. Cognitive strategies/guided imagery: the patient is b. Manual resistance; PNF patterns can be used to instructed to focus on relaxing the body, visualiz- ing calmness and relaxation. promote synergistic control, improve timing a. The patient focuses on letting go of all muscu- using techniques of slow reversals or slow lar effort, letting tension melt away. reversal hold. b. The patient focuses on a relaxing environment c. Weights, pulleys, hydraulics, elastic resistance or pleasant images to promote relaxation, e.g., bands, mechanical or electromechanical lying on a tropical beach in the warm sunshine. devices. 4. Active range of motion: AROM can be used to 4. Stretching exercises. reduce tension by moving body segments slowly. F. Teach Activity Pacing and Energy Conservation 5. The technique of Rhythmic Rotation (RRo) Strategies as Appropriate involves slow, passive, rotational movements of 1. The patient with ataxia has increased energy the limbs or trunk and can be very effective in expenditure and can experience debilitating relieving muscular tension and spasticity, e.g., fatigue. hooklying with both lower extremities on a Swiss ball, gently rocking the knees on the ball from VI. Relaxation Training side-to-side. 6. Slow vestibular stimulation: low vestibular stim- A. Relaxation ulation applied with gentle rocking techniques can 1. Relaxation refers to a conscious effort to relieve also be used to enhance relaxation, e.g., gentle excess tension in muscles. rocking of the infant with colic. a. Excess muscle tension can cause pain, which 7. Biofeedback training can be an effective modality leads to muscle spasm, which in turn produces to promote relaxation, e.g., training to reduce the more pain. To break the pain/spasm cycle, level of tension in the frontali muscle. patients must learn to relax tense muscles. 8. Stress management/life-style adaptation tech- b. Excess tension in tissues can result from main- niques. taining a constant posture or sustaining muscle a. Careful identification and evaluation of life contractions for a period of time. Abnormal stressors, e.g., Life Events Scale, Holmes-Rahe shortening or lengthening of muscles and liga- Social Readjustment Scale, The Hassles Scale, ments is termed postural stress syndrome is critical in developing an appropriate plan of (PSS). c. Habituation of compensatory movement pat- terns that contribute to the persistence of pain is termed movement adaptation syndrome (MAS). 2. Awareness of prolonged muscle tension is accom-

care to reduce chronic stress. Stress control Therapeutic Exercise Foundations 291 techniques include both cognitive and physical strategies. and enhance movement; similar movements on b. Life style modification reduces frequency of land may be more difficult or impossible to per- high stress situations and events. It is important form. to ensure adequate rest and activity, and ade- 2. Allows greater freedom and range of movement quate nutrition. than is permitted in whirlpools or Hubbard tanks. c. Enhance coping skills: ensure the patient main- 3. Pools or tanks with a walking track, with or with- tains orne level of control and decision-mak- out a treadmill, are used to enhance gait and ing. endurance. d. Maximize effective use of social support sys- C. Physics Related to Aquatic Exercise tern. 1. Buoyancy: is the upward force of the water on an C. Common Errors Associated with Relaxation immersed or partially immersed body or body Training part. It is equal to the weight of the water that it 1. Lack of awareness of the effects of the environ- displaces (Archimedes' principle). This creates an ment on an individual. Failure to have the patient apparent decrease in the weight and joint unload- in a low stress environment and comfortably posi- ing of an immersed body part, thereby allowing tioned. easier movement in water. 2. Lack of awareness of stress factors affecting the 2. Cohesion: the tendency of water molecules to patient. Failure to evaluate stressors carefully and adhere to each other. The resistance encountered incorporate stress management techniques. while moving through water is due to cohesion; 3. When using progressive relaxation techniques, some force is needed to separate water molecules. progressing too fast from one body segment to 3. Density: the mass per unit volume of a ubstance. another, e.g. distal to proximal body parts. Failure The density of water is proportional to its depth; to combine slow deep breaths with each contrac- deeper water must support the water above it. tion and relaxation. 4. Hydrostatic pressure: the circumferential water 4. Lack of effective training of kinesthetic awareness. pressure exerted on an immersed body part. A Patients do not recognize when their muscles are pressure gradient is established between the sur- tense. They perceive the tense muscle as normal, face water and deeper water due to the increase in not needing any relaxation intervention. water density at deeper levels. a. Pascal's law states that the pressure exerted on VII. Aquatic Exercise an immersed body part is equal on all surfaces. A. Goals and Outcomes b. Increased pressure counteracts effusion and 1. Motor function and motor learning are enhanced. 2. Range of motion and flexibility are improved. edema, and enhances peripheral blood flow. 3. Postural control, biomechanical alignment, and 5. Turbulence: movement of a body part through symmetrical weight distribution are improved. 4. Strength, power, and endurance are improved. water creates circular motion of the water (eddy 5. Sensory control and integration of sensory systems current) near the surface of the part producing fric- (somatosensory, visual, and vestibular) are tional drag. improved. a. As speed of movement increases, greater 6. Performance, independence, and safety in balance, gait and locomotion are improved. resistance is encountered. 7. Aerobic capacity and endurance are improved. b. Moving through turbulent water creates greater 8. Relaxation, reduction of pain and decreased mus- cle spasm are enhanced. resistance as compared to calm water. c. Use of equipment (e.g., paddle or boot) B. Strategies I. Immersion in pools or tanks is used to facilitate increases resistance and drag as the patient exercise. Water buoyancy, buoyant devices, and moves through water. various depths of immersion decrease body weight D. Thermodynamics 1. Water temperature affects body temperature and performance. 2. Water temperature is determined by specific needs of patient and intervention goals. a. Cooler temperatures are used for higher inten- sity exercise.

292 b. Can be used for PWB gait training. 6. Lower extremity reciprocal movements are b. Warmer temperatures are used to enhance mobility and flexibility, e.g., patients with enhanced by use of a kick board and using kicking arthritis. movements. 7. Aerobic conditioning is enhanced with deep water c. Ambient air temperature should be close to walking or running, high step marching. water temperature (e.g., within 3°C). Progression is to reduced water levels to land walking/running. 3. There is decrea ed heat dissipation through sweat- a. Immersed equipment (e.g., cycle ergometer, ing with immersion. treadmill, or upper body ergometer) can be 4. At temperatures >37°C patients will have used to enhance conditioning. increased cardiovascular demands at rest and dur- b. Swimming is an excellent aerobic training ing exercise. activity. c. Regular monitoring of exercise responses, e.g., 5. At temperatures <25°C patients will have difficul- heart rate, ratings of perceived exertion, is ty maintaining core temperature. required. 8. Treatment time varies with the type of activity, E. Special Equipment patient tolerance, and level of skill. 1. Buoyancy assistance devices: inflatable cervical G. Contraindications collar, flotation rings, buoyancy belt or vest, kick- 1. Bowel or bladder incontinence. board. 2. Severe kidney disease. 2. Buoyant dumbbells (swimmers) are used for 3. Severe epilepsy. upright or horizontal support. 4. Severe cardiac or respiratory dy function, e.g., 3. Webbed gloves and hand paddles are used to cardiac failure, unstable angina, everely reduced increase resistance to upper extremity movement. vital capacity, unstable blood pressure. 4. Fins and boots are used to increase resistance to 5. Severe peripheral vascular disease. lower extremity movement. 6. Large open wounds, skin infection , colostomy. 7. Bleeding or hemorrhage. F. Exercise Applications 8. Water and airborne infections, e.g., influenza, 01 1. Movement horizontal to or upward toward the infections. water surface (active assistive exercise) is made H. Precautions easier due to the buoyancy of water. A flotation 1. Fear of water, inability to swim. device may be needed to support very weak 2. Ataxic patients with postural instability. patients. 3. Patients with heat intolerance, e.g., patient with 2. Movement downward into the water is more diffi- multiple sclerosis. cult because of the buoyancy of water. 4. Use waterproof dressing on mall open wounds a. A flotation device or hand-held paddle can be and intravenous lines. used to increase the resistance. b. A paddle turned to slice through the water decreases the resistance. 3. Resi tance exercise can be controlled by the speed of the movement. a. Resistance is increased with increased velocity of movement due to the cohesion and turbu- lence of the water. b. Slower movements meet less resistance. c. Ataxic movements are slowed and more con- trolled against the re istance of water. 4. Stretching exercises can be assisted by the buoy- ancy of water. 5. The amount of weightbearing on the lower extremities is determined by the height of the water/level of immersion (buoyancy) relative to the upright patient. a. The greater the water depth, the less the weight/loading on extremities.

CHAPTER 10 THERAPEUTIC MODALITIES John Carlos, Jr. I. Superficial Thermotherapy c. Mu de and joint show least temperature change, if any, depending on size of structure. A. Physics Related to Heat Transmission 1. Conduction: heat transfer from a warmer object to 2. Physiological effects on body systems and struc- a cooler object through direct molecular interaction tures to small surface area heat modalities are list- of objects in physical contact. Conductive modalities: ed in Tables 10-2 and 10-3. hot pack , paraffin. 2. Convection: heat transfer by movement of air or D. Goals and Indications for Superficial Thermotherapy fluid from a warmer area to a cooler area or movinbo I. Modulate pain; increa e connective ti ue extensi- past a cooler body part. Convective modalities: bility; reduce or eliminate soft tissue inflammation whirlpool, Hubbard tank, fluidotherapy. and swelling; accelerate the rate of tissue healing; 3. Radiation: transfer of heat from a warmer object to reduce or eliminate soft tissue and joint restriction a cooler object through the transmission of elec- and muscle spasm. tromagnetic energy without heating an intervening 2. Preparation for electrical stimulation; massage; medium. Infrared waves absorbed by cooler body. passive and active exercise. Radiation modality: infrared lamp. E. Precautions for Use of Superficial Thermotherapy B. Physiological Effects of General Heat Application I. Cardiac insufficiency; edema; impaired circula- Large areas of the body surface area exposed to heat tion; impaired thermal regulation; metal in treat- modality; e.g., whirlpool (hip and knee immersed) ment site and open wounds. and Hubbard tank (lower extremities and trunk immersed) (Table 10-1). TABLE 10-1 - PHYSIOLOGICAL EFFECTS OF GENERAL HEAT APPLICATION C. Physiological Effects of Small Surface Area Heat Application Heat modality applied to discrete area of INCREASED DECREASED body; e.g., low back, hamstring, neck. I. Body tissue responses to superficial heat. Cardiac output Blood pressure a. Skin temperature rises rapidly and exhibits Metabolic rate Muscle activity (sedentary effect) greatest temperature change. Pulse rate Blood to internal organs b. Subcutaneous tissue temperature rises less rap- Respiratory rate Blood flow to resting muscle idly and exhibits smaller change. Vasodilation Stroke volume

294 F. Contraindications to the Use of Superficial alert personnel of any untoward effects of treatment. Thermotherapy Check patient frequently during initial treatment. 1. Acute and early subacute traumatic and inflamma- A patient with impaired cognitive function, such tory conditions, decreased circulation, decreased as Alzheimer's disease, senility or mental retardation, sensation, deep vein thrombophlebitis, impaired should be checked frequently (every five minutes) cognitive function, malignant tumors, tendency during treatment. toward hemorrhage or edema, very young and 6. Dry and inspect skin at conclusion of treatment. very old patients. Additional contraindications rel- 7. Specific procedure for each physical agent listed ative to specific modality listed separately. separately. H. Superficial Heating Physical Agents G. General Treatment Preparation for Thermotherapy 1. Hot packs. and Cryotherapy a. Description: a canvas pack filled with silica gel 1. The application of physical agents must be per- formed by a qualified physical therapist or personnel which is heated by immersing in water between supervised by a physical therapist (physical therapist 1650 -170°p' assistant, affiliating physical therapist or physical b. Method of heat transmission: conduction. therapist assistant student). The treatment and c. Method of application. expected sensations must be explained to the (1) Place pack(s) into terry cloth cover. Place patient. 2. Place patient in comfortable position. one folded towel between patient and pack 3. Expose treatment area and drape patient properly. for hygienic purpose . 4. Inspect skin and check temperature sensation prior (a) One towel method: to treatment. 5. If patient has good cognitive function, a call bell or • Fold four towels in half, width-wise. other signaling device can be given to patient to • Place each towel on top of the other, forming eight layers of toweling. • Place towels on treatment area. TABLE 10-2 - INCREASED PHYSIOLOGICAL RESPONSES OF BODY SYSTEMS AND STRUCTURES TO LOCAL HEAT APPLICATION SYSTEM/STRUCTURE MECHANISM a. Blood flow b. Capillary permeability Dilation of arteries and arterioles c. Elasticity of nonelastic tissues Increase in capillary pressure d. Metabolism Increased extensibility of collagen tissue For every 1Q°C increase in tissue temperature there is a two-threefold increase rate of cellular e. Vasodilation oxidation (Van't Hoff's Law) Activation of axon reflex and spinal cord reflex, release of vasoactive agents (bradykinin, f. Edema histamine, prostaglandin) Increased capillary permeability TABLE 10-3 - DECREASED PHYSIOLOGICAL RESPONSES OF BODY SYSTEMS AND STRUCTURES TO LOCAL HEAT APPLICATION SYSTEM/STRUCTURE MECHANISM a. Joint stiffness b. Muscle strength Increased extensibility of collagen tissue and decreased viscosity c. Muscle spasm Decreased function of glycolytic process Decreased firing of II afferents of muscle spindle and increased firing of Ib GTO fibers reduces d. Pain alpha motor neuron activity and thus decreases tonic extrafusal activity Presynaptic inhibition of A delta and C fibers via activation of A beta fibers (Gate Theory), disruption of pain-spasm cycle

o Place pack on towels and cover pack Therapeutic Modalities 295 with folded towel to retard heat loss. paper, and covered with several layers (b) Two-towel wrap method: of toweling and secured with tape or o Fold two towels lengthwise and rubber bands. place one perpendicular over the (e) The patient places the part in a com- other, forming a cross. fortable or elevated position for 15-20 o Place pack in the center of the towels. minutes. o Fold the ends of the towels over the (2) Dip and immer ion method: the procedure pack, forming eight layers oftoweling follows steps (a) - (c) above, except the part on top of the pack. Invert pack plac- remains comfortably in the bath after the ing the eight layers of toweling on final dip. patient. c. Treatment temperature: 125-127°F. d. Treatment time: 15-20 minutes. (2) Place pack on patient. If patient must be e. Indications: painful joints due to arthritis or other placed on pack, use additional towels and inflammatory conditions in the late subacute or pillow to upport patient. Thi will minimize chronic phase, joint stiffness. Mo t often used discomfort or excessive heating of treatment on wrists and hands. area due to weight of patient on pack. f. Contraindications: allergic rash, open wounds, recent scars and sutures, skin infection . (3) Secure the pack to the patient with towels, 3. Fluidotherapy i no longer tested on the NPTE. sandbags or straps, if needed. 4. Infrared lamp is no longer tested on the NPTE. 5. Hydrotherapy (whirlpool and Hubbard tank). (4) Cover pack with folded towel to retard heat Description: partial or total immer ion baths in which loss. the water is agitated and mixed with air to be directed against or around the affected part. Patients can move (5) Phy ical therapist or physical therapist the extremities easily due to the buoyancy and thera- a si tant should check the skin periodically peutic effect of the water. during treatment. a. Method of heat transmi sion: convection. b. Physics related to hydrotherapy. d. Temperature of the water bath: 165°-170°F. (1) Specific heat is the heat-absorbing capacity e. Treatment time: 20-30 minutes. of water. The amount of heat a gram of f. Indications/contraindications: refer to sections I, water absorbs or gives off in changing the temperature one degree centigrade. The D, E, and F. specific heat of water is about four times 2. Paraffin bath. Therapeutic application of liquid that of air. (2) Thermal conductivity is the capability of a paraffin to a body part for the transmission of heat. liquid, gas or solid to conduct heat. Paraffin bath is a thermostatically controlled unit (3) Buoyancy is the upward force of the water that contains a paraffin wax and mineral oil mix- on an immersed or partially immersed body ture in a 6: 1 or 7: 1 ratio. The paraffin/mineral oil or body part which is equal to the weight of mixture melts between 118°P-130op and is nor- the water that it displaced (Archimedes' mally se1f- terilizing at temperatures of 175-180 Principle). degrees F. Paraffin is primarily applied to small, (4) Viscosity is the ease at which fluid molecules irregularly-shaped areas such as the wrist, hand move with respect to one another. High tem- and foot. perature lowers the viscosity of the fluid. a. Method of heat tran mission: conduction. (5) Hydrostatic pressure is the circumferential b. Procedure. water pressure exerted on an immersed body part. A pressure gradient is estab- (1) Glove method (dip and wrap). lished between the urface water and deeper (a) Remove jewelry or cover jewelry with water due to the increase in water density at everal1ayers of gauze, ifjewelry cannot deeper levels. be removed. (b) Wash the part and check for infection and open areas. (c) The part is dipped several times to apply six to twelve layers of paraffin. (d) After the paraffin has solidified, the part is wrapped with plastic wrap or waxed

296 to bracket in the tank. Remove the suspended hoist when stretcher is resting on bottom of (6) Cohesion is the tendency of water mole- tank or halt descent of lift at desired level. cules to adhere to one another. The resist- (6) Thrn on agitator and adjust the force, direc- ance encountered while moving through tion, depth, and aeration. water is partially due to the cohesion of the (7) Monitor patient's response and tolerance to water molecules and force needed to sepa- the whirlpool. rate them. (8) At end of treatment, remove patient on to stretcher or lift. Dry and inspect skin. (7) Density of the water is proportional to its (9) Clean and dry whirlpool. depth. Deeper water must support the water e. Treatment temperature: varies with size and above it and is more dense. status of area treated. (I) 103°F-110°F whirlpool. c. Method of application: whirlpool. (2) 100°F Hubbard tank. (1) Fill the tank with water to the proper level (3) 95°F-100°F peripheral va cular disease. and to the desired temperature. Whirlpool (4) 92°F-96°F open wounds. liners may be used for patients with burns, f. Treatment time: 20 minute . Up to 30 minutes, wounds, or who are infected with blood- if other therapeutic procedures are also being borne pathogens (human immunodeficiency performed. virus or hepatitis-B virus). g. General cleaning procedures. Procedures may (2) Add disinfectant if open wounds are present. vary in different ettings. Common antibacterial agents: sodium (1) After draining water from tank, rinse the hypochlorite (bleach), dilution of 200 parts entire tank including the openings in agitator per million (ppm); povidone-iodine, dilution and all drains. of 4 ppm; Chloramine-T, 100-200 ppm. (2) Wipe all areas that were in contact with (3) Standard precautions (gowns, goggles, water with a clean dry towel. masks, and gloves) should be applied when (3) Wash the inside of the tank, outside of the working in infected environment, particularly agitators and the drains with disinfectant when working with possibility of splashing. diluted in warm water. Also wash agitators, (Refer to Table 5-2). thermometers and all equipment used in (4) Assist patient in immersing his or her body treatment. Some tanks have a hose that can or body part into the tank. be used to spray tank. Allow disinfectant to (5) Pressure points should be padded for stand for at least one minute. patient comfort and to minimize compres- (4) Place agitator in bucket filled with water sion of blood vessels and nerves. Keep tow- and di infectant, covering all openings with els out of water. solution. Thrn on agitator for about 20-30 (6) Adjust agitator to desired position. seconds. Thrn off motor and remove agitator (7) Thrn on agitator and adjust the force, direc- from bucket. tion, depth, and aeration. (5) Rinse the entire tank and all equipment (8) Monitor patient's response and tolerance to until all residue is removed. Following use the whirlpool. with patients with wounds or burn , refill (9) At end of treatment, dry and inspect skin. the tank with hot water and disinfectant and allow solution to stand for five minutes d. Method of application: Hubbard tank. (with or without agitator). (I) Fill the tank with water to the proper level (6) Repeat step (4) with clean water. You may and to the desired temperature. wish to rinse that tank a second time with (2) Add disinfectant, if open wounds are present hot water (110°F-115°F) to hasten drying. [refer to section 5c(2)]. (7) Wipe both the inside and the outside of the (3) Position and secure patient supine on tank dry with a clean towel. stretcher or pneumatic lift. h. Indications: decubitu ulcers, open burns and (4) Lift patient over edge of tank and slowly lower to water line to enable patient to get accustomed to the water temperature. (5) Continue to lower patient into the water with head elevated. Secure head end of stretcher

wounds, post-hip fractures, post- urgical con- Therapeutic Modalities 297 ditions of hip, subacute and chronic muscu- 10 keletal conditions of neck, shoulders and 7. Aquatic Therapy. back, rheumatoid arthritis. a. A form of hydrotherapy used primarily for 1. Precaution. weightbearing activities, active exercise or hor- (1) Decreased temperature sensation; impaired izontal floating activities. Swimming pools or Hubbard tanks with or without walking troughs cognition; recent skin graft; incontinence; and treadmill units are used. confusion/disorientation; deconditioned b. Principles. state; hydrophobia with full immersion. (1) Movement horizontal to or upward toward j. Contraindication. the water surface (active assi tive exercise) (1) Bleeding; wound maceration; cardiac insta- i made easier by the buoyancy of the bility; profound epilepsy with full immer- water. A flotation device may be used as ion. well. h. Electrical safety: afety precautions must be (2) Movement downward is more difficult. A taken with any modality that potentially exposes flotation device would increa e resistance. the patient to electrical hazard from faulty elec- (3) Increasing speed of movement increa es trical connections. resistance becau e of turbulence and cohe- (I) A ground fault circuit interrupter should be sion of water. Use of hand-held paddles installed at the circuit breaker of receptacle held width-wise will increase resistance. of all whirlpools and Hubbard tanks. The Streamlining can be achieved by turning electrical circuit is broken if current is the paddle and slicing through the water. diverted to the patient (macroshock) who is (4) Amount of weightbearing can be deter- grounded rather than to a grounded modality. mined by the water depth. The greater the (2) All whirlpool turbines, tanks and motors depth, the less the load on the extremeties and motors u ed to lift patients should be because of buoyancy. checked for current leakage (broken or c. Water temperature i 92-98 degrees F. frayed connections). d. Treatment time varies with patient tolerance. 6. Nonimmersion irrigation device. e. Open wounds and skin infections must be cov- a. Small, hand-held electric water pump that pro- ered. duce a water jet to create a shearing force to f. Goals are to improve standing balance: partial 100 en ti ue debris. Some devices produce a weightbearing ambulation; aerobic exercise; pulsed lavage and include suction to remove improve ROM; increase muscle strength via debris. active assistive, active or resistive exercise. b. Procedure. g. Contraindications are incontinence; urinary (1) Treatment hould take place in an enclosed tract infections; severe epilepsy; unprotected area. open wound ; unstable blood pressure or (2) Face and eye protection, gloves and water- severe cardiopulmonary dysfunction. proof gown are required. (3) Sterile, warm saline is used. Antimicrobials TABLE 10-4 - PHYSIOLOGICAL EFFECTS may be added. OF GENERAL COLD APPLICATION (4) Select appropriate treatment pressure, usu- ally 4-8 psi. Pressure may be increased in DECREASED INCREASED presence of large amounts of necrotic tis- sue or tough eschar. Pressure should be Metabolic rate Blood flow to internal organs decrea ed with bleeding, near a major ves- Pulse rate Cardiac output sel or if a patient complain of pain. Respiratory rate Stroke volume (5) Treatment time is usually 5-15 minutes, Venous blood pressure Arterial blood pressure once a day. Wound size and amount of Shivering (occurs when core necrotic tissue may increase treatment temperature drops) parameters.

298 II. Cryotherapy b. Subcutaneous temperature falls less rapidly and displays smaller temperature change. A. Physics Related to Cryotherapy Energy Transmission Abstraction is the removal of heat via conduction or c. Muscle and joint show least temperature evaporation. change, requiring longer cold exposure. 1. Conduction: transfer of heat from a warmer object to a cooler object through direct molecular interaction 2. Vasoconstriction of skin capillaries resulting in of objects in physical contact. Conductive modali- blanching of skin in center of contact area and ties: cold pack, ice pack, ice massage, cold bath. hyperemia due to histamine reaction, around the 2. Evaporation (heat of vaporization): highly volatile edge of contact area in normal tissue. liquids that evaporate rapidly on contact with warm object. Evaporative modality: vapocoolant 3. Cold-induced vasodilation: cyclic vasoconstriction sprays (Fluori-Methane). Continued use question- and vasodilation following prolonged cold expo- able due to environmental concerns. sure (>15 minutes). Occurs mostly in hands, feet and face where arteriovenous anastomoses are B. Physiological Effects of Large Surface Area Cold found. Called the \"hunting\" reaction. Recent stud- Application (Table 10-4). ies have questioned the clinical significance of this reaction. C. Physiological Effects of Small Surface Area Cold Application 4. Physiological effects on body systems and struc- 1. Effects of cold application on body tissues. tures to small surface area cold modalities (Tables a. Skin temperature falls rapidly and exhibits great- 10-5 and 10-6). est temperature change. 5. Adverse physiological effects of cold due to hypersensitivity. TABLE 10-5 - DECREASED PHYSIOLOGICAL RESPONSES OF BODY SYSTEMS AND STRUCTURES TO LOCAL COLD APPLICATION SYSTEM/STRUCTURE MECHANISM a. Blood flow b. Capillary permeability Sympathetic adrenergic activity produces vasoconstriction of arteries, arterioles and venules c. Elasticity of nonelastic tissues Decreased fluids into interstitial tissue d. Metabolism Decreased extensibility of collagen tissue e. Muscle spasm Decreased rate of cellular oxidation Decreased firing of II afferents of muscle spindle, increased firing of Ib GTO fibers reduces alpha f. Muscle strength motor neuron activity and thus decreases tonic extrafusal activity g. Spasticity Decreased blood flow, increase in viscous properties of muscle (long duration: >5-10 min.) Decrease in muscle spindle discharge (afferents: primary, secondary), decreased gamma motor h. Vasoactive agents neuron activity Decreased blood flow TABLE 10-6 - INCREASED PHYSIOLOGICAL RESPONSES OF BODY SYSTEMS AND STRUCTURES TO LOCAL COLD APPLICATION SYSTEM/STRUCTURE MECHANISM a. Joint stiffness Decreased extensibility of collagen tissue and increased tissue viscosity b. Pain threshold Inhibition of A delta and C fibers via activiaton of A beta fibers (Gate Theory), interruption of c. Increased blood viscosity pain-spasm cycle, decreased sensory and motor conduction, synaptic transmission slowed or d. Muscle strength blocked. Decreased blood flow in small vessels facilitates red blood cells adhering to one another and vessel wall-impeding blood flow. Facilitation of alpha motor neuron (short duration: 1-5 min)

a. Cold urticaria: erythema of the skin with wheal Therapeutic Modalities 299 formation associated with severe itching due to histamine reaction. and apply to body part. (2) Secure towel manually. b. Facial flu h, puffiness of eyelids, respiratory (3) Exchange towels when applied towel problems and in severe cases, anaphylaxis (decreased blood pressure, increased heart rate) warms up, usually in 45-60 seconds. with syncope are also related to histamine (4) Repeat procedure to reach or maintain effect. release. c. Treatment time: 10-15 minutes. 4. Ice massage. Description: ice cylinder formed by D. Goals and Indications for Cryotherapy freezing water in a paper cup or styrofoam cup. I. Modulate pain; reduce or eliminate soft tissue Salt may be added to create a colder lush mixture. inflammation or swelling; reduce muscle spasm; A lollipop stick or wooden tongue depressor may reduce pa ticity. or may not be placed in water during freezing process. During the application of ice massage, the E. Precautions patient will usually experience the following 1. Hypertension; impaired temperature sensation; sequence of physiological response stages: cold, open wound; over superficial nerve; very old or burning, aching, and numbness. young. a. Method of heat transmission: conduction. b. Method of application. F. Contraindications to Use of Cryotherapy (I) Remove ice from container. Wrap ice with I. Cold hypersensitivity (urticaria); cold intolerance; cryoglobulinemia; peripheral vascular disease; towel or wash cloth, if ice has no lollipop impaired temperature sensation; Raynoud's disease. stick. If ice is retained in container, tear off bottom half and hold top half. G. Procedures (2) Apply the ice massage to an area no larger 1. Cold packs. Description: vinyl casing filled with then 4\"x 6\" in slow (2\"/sec) overlapping silica gel or sand-slurry mixture. circles or overlapping longitudinal strokes, a. Method of heat transmission: conduction. each stroke covering one-half of previous b. Method of application. circle or stroke. If treating a large area, (1) Keep the patient warm throughout treatment. divide into smaller areas. (2) Dampen a towel with warm water, wring (3) Do not massage over bony area or superficial out excessive water, fold in half, width-wise nerves (e.g., peroneal/fibular). and place cold pack on towel. (4) Use a towel to dab excess water from treat- (3) Place pack on patient and cover with dry ment area. Ice will melt rapidly initially, but towel to retard warming. rate of melting will slow as skin cools. (4) Secure pack.. (5) Continue treatment until anesthesia is c. Treatment temperature: packs are maintained achieved. in refrigerated unit at O°F-IO°F. c. Treatment time: 5-10 minutes or until analgesia d. Treatment time: 10-20 minutes. occurs. e. Indications/contraindications: see general infor- 5. Vapocoolant spray. Description: a non-toxic, non- mation. flammable volatile liquid which produces rapid 2. Ice packs. Description: crushed ice folded in moist cooling when a fme spray is applied to the skin. towel or placed in plastic bag covered by moist towel. Vapocoolant sprays are primarily used to reduce a. Method of heat transmission: conduction muscle spasm, desensitizing trigger points. The (abstraction). use of vapocoolant sprays is being questioned due b. Method of application. to the chloroflourocarbon ingredients in the spray (I) Apply the ice pack to body part. and its effect on the environment. (2) Cover pack with dry towel. a. Method of heat tran mission: evaporation. c. Treatment time: 10-20 minutes. b. Procedure (spray and stretch method). 3. Ice towel. Description: towels soaked in ice slush. (1) Invert container, nozzle down, hold about Water is added to shaved ice to produce an ice slush. 18\"-24\" from treatment area. a. Method of heat transmission: conduction. (2) Spray at 30° angle and sweep spray over b. Method of application. treatment at 4\"1 econd. (1) Immerse two towel in slush, wring one out

300 m. Acoustic Radiation: Ultrasound (3) Allow liquid to completely evaporate A. Biophysics Related to Ultrasound before applying next sweep. Caution! Do 1. Conversion: mechanical energy produced by not frost skin. sound waves at frequencies between 85 KHz and 3 MHz and delivered at intensities between 0 and 3 (4) The muscle should be passively stretched W/cm2 is absorbed by body tissues and changed to before and during application. thermal energy. 2. Applicator contains a piezoelectric crystal (trans- (5) Cover the entire treatment area, starting at ducer). the pain site and moving to the area of a. Transducer converts electrical energy into referred pain. acoustical energy via reverse piezoelectric effect. b. Alternating voltage causes mechanical defor- (6) Have patient perform active exercise after mation of the crystal. spraying. c. Crystal resonates (vibration) at current frequency. d. Oscillating crystal produces sound waves with c. Treatment time: 10-15 minutes. little dispersion of energy (collimated beam). d. Indications: myofascial referred pain, trigger e. Oscillating sound wave produces radiation or mechanical pressure waves in the tissue fluid points. medium. The molecules within the tissue e. Contraindications: refer to section IIF. vibrate and the resulting friction produces heat. 6. Contra t baths. Description: the alternating 3. Transducer size. immersion of a body part in warm and cold water a. Ultrasound transducers come in a variety of to produce a va cular exercise through active sizes from 1 cm2 to 10 cm2• 5 cm2 is the most vasodilation and vasoconstriction of the blood ves- commonly used. sels. The effectiveness of this method in raising b. Transducer size should be selected relative to deep tissue temperature via increased circulation the size of the treatment area (one cm2=wrist; of deep vessels has been questioned. It may be 5cm2=shoulder, leg). useful in promoting pain modulation. c. Effective radiating area (ERA). a. Method of heat transmission: conduction. (1) The ERA is the area of the faceplate (crys- b. Procedure. tal size) which is smaller relative to the soundhead. (1) The treatment usually begins in warm (80- 4. Spatial characteristics of ultrasound. 110 degrees F) water. a. During continuous ultrasound, spatial charac- teristics of ultrasound are predominant. (2) Place part in the warm water for 4 minutes, b. Continuous US is applied to achieve thermal then transfer to cold water for I minute. effects (e.g., chronic conditions). c. Ultrasound energy (intensity) is not uniformly (3) Immerse part in warm water for 4 minutes. distributed over the surface of the transducer, (4) Continue sequence of 4:1. End in warm because the energy is mechanically blocked by the adhesive bonding of the crystal in the trans- water. ducer and the pressure waves interfere with (5) The patient's condition may determine the each other as they radiate from different areas of the crystal. ending temperature. Ending in cold water d. Uneven intensity produces a high level of energy may be more beneficial if reducing edema in the center of the ultrasound beam relative to the is the goal. surrounding areas. Thi effect produces a \"hot c. Treatment temperature. spot\" (peak spatial intensity) in the beam. Moving (1) Hot water: 100°F-llO°F. the soundhead or using pulsed ultrasound will (2) Cold water: 55°F-65°F. tend to reduce the effect of the hot spot. (3) During initial treatment you may wish to begin with the upper end of the cold range and the lower end of the hot range. d. Treatment time: 20-30 minutes. e. Indications: any condition requiring stimulation of peripheral circulation in limbs, peripheral vascular disease, sprains, strains, and trauma (after acute condition abates). f. Contraindications: advanced arteriosclerosis, arterial insufficiency, loss of sensation to heat and cold.

e. Spatial average inten ity. The total power Therapeutic Modalities 301 (watt) divided by the area (cm') of the trans- thre hold, increased collagen tissue exten ibility, alteration of nerve conduction velocity, increased ducer head. This i typically the measurement enzymatic activity, and increased tissue perfusion. b. Increased temperature at tis ue interfaces due to u ed in documenting ultra ound treatments reflection. Tissue interfaces could be bone/liga- ments, bone/joint capsule and bone/muscle. (0.25 w/cm'-2.0 w/cm 2 c. Excessively high temperatures may produce a ). sudden trong ache due to overheating of periosteal tissue (periosteal pain). Reduce f. Beam nonuniformity ratio (BNR) This is the intensity or increase surface area of treatment if periosteal pain is expressed by patient. ratio of the patial peak intensity to the spatial d. Insufficient coupling agent may produce discomfort due to a \"hot spot\", which is the average intensity. The lower the BNR, the more uneven distribution of the acoustical energy through the sound head. However, this is a uniform the energy distribution, the less risk of greater problem if the stationary technique is used. tissue damage. BNR should be between 2: 1- 2. Non-thermal: generated by very low intensity or pulsed (intermittent) sound energy. Pul ed US is 6: 1. An ideal 1: I ratio i not technically fea ible. related to duty cycle. Typically duty cycle of 20- 50% for non-thermal intervention. 5. Temporal characteristics of ultra ound. a. Cavitation: alternating compression (condensa- tion phase) and expansion (rarefaction phase) a. During pulsed ultra ound, temporal character- of small gas bubbles in tissue fluids caused by mechanical pressure waves. istics of ultrasound are important. (1) Stable cavitation: gas bubbles resonate but b. Pulsed US i applied when nonthermal effects no tissue damage. Stable cavitation may be responsible for diffusional changes in cell are desired. (e.g., acute soft tissue injuries). membranes. (2) Unstable cavitation: evere collap e of gas c. Duty cycle. The fraction of time the US energy bubbles during compre sion pha e of ultra- sound can result in local tissue de truction is on over one pulse period (time on + time off). due to high temperatures. (a) Acoustic streaming: movement of fluids For example, a 20% duty cycle could have an along the boundaries of cell membranes on time of 2 ms and an off time of 8 ms. A duty resulting from mechanical pressure wave. Acoustic streaming may produce cycle of 50% or less is considered pulsed US. alterations in cell membrane activity, increased cell wall permeability, A duty cycle of 51 %-99% produces less increased intracellular calcium, increased macrophage re pon e, and acoustic energy and less heat. increa ed protein synthesis. Acoustic streaming may be of orne value in d. Temporal peak intensity. The peak intensity of accelerating tissue healing. C. Goals and Indications US during the on-time pha e of the pulse period. 1. Modulate pain; increase connective tissue extensi- bility; reduce or eliminate soft tissue inflammation; e. Temporal average intensity. The US power accelerate rate of tissue healing; reduce or eliminate soft tissue and joint restriction and muscle spasm. averaged over one pulse period. f. Attenuation. The reduction of acoustical energy a it passes through oft tissue. Absorption, reflection and refraction affect attenuation. Ab orption is highest in in tissues with high collagen and protein content (muscles, tendons, ligament, cap ules). The scattering of sound waves re uting from reflection and refraction produces molecular friction that the sound wave must overcome to penetrate tissues. 6. Depth of penetration: 3-5cm. a. At 3 MHz, greater heat production in superficial layer due to greater catter (attenuation) of ound wave in superficial ti sue; e.g., temporo- mandibular joint. b. Increased heat production in deep layers at 1 MHz due to Ie s scatter in uperficial tissues and thus more US energy is able to penetrate to deeper tis ues. B. Physiological Effects of Ultrasound 1. Thermal: produced by continuous sound energy of sufficient intensity. Range: 0.5-3w/cm'. US intensity will vary depending upon ti sue type and pathology. a. Increased tissue temperature, increased pain