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ADVANCE For Physical Therapy and Rehab Medicine: High Intensity Exercise for Seniors

Extreme exercises can target weight-bearing and balance, if used properly


First, the good news: seniors are living longer and healthier lives than ever before. Thanks to medical advances and the application of evidence-based research, age-related problems and chronic illnesses like heart disease, diabetes, and many others are being managed better than ever before. More efficient and effective management of these previously debilitating condi- tions means aging adults are experiencing longer life expectancies.


While this is certainly a positive development, longer life expectancies can foster a host of other health issues that need to be addressed in order to ensure a continued independent and healthy lifestyle. The most critical health issue created from this longevity that requires addressing is immobility. Caused by loss of muscle strength, flexibility, balance, and depth perception, immobility can lead to anything from loss of independence to a life-changing falling accident. Take, for example, the sobering fact that, according to the Centers for Disease Control, one in every three adults over the age of 65 suffers from a serious fall, yet less than half talk to their healthcare providers about it. Given this, and the fact that falls are the leading cause of both fatal and nonfatal injuries to seniors, addressing the issue of immobility is more pressing and imminent than ever.


It is becoming abundantly clear that one of the most important pieces of the senior wellness puzzle is special- ized physical therapy—specifically high intensity therapy—designed to help seniors stay upright, active, and mobile for as long as possible. With Medicare only covering 15 hours of physical therapy per year for aging adults, physical and occupational therapists working with seniors need to have a comprehensive understanding of the physical and mental complexities of aging, as well as current and emerging evidence-based research in order to build and implement the most beneficial physical therapy programs possible.


Risky Business

The first step in the process of understanding the highly specialized therapeutic needs of aging seniors is appreciating the risk factors for the age-related loss of strength and balance that increases the risk of a fall. Consider the eye-opening fact that we lose about 10 percent of our strength every decade after the age of 30. Thoracic kyphosis (curvature of the spine), along with reduced muscle strength, plays an important role in increasing body sway, gait unsteadiness, and a decreased ability to step over obstacles of different heights. Balance, so essential for avoiding falls, also degrades as we age and our reaction time slows. The nervous system does not respond as quickly when we are older, so reacting to being off balance can be a chal- lenge. Loss of sensation is also an issue: the lack of feeling in the legs or feet can contribute to balance difficulties. Loss of vision-especially in dim lighting-and poorer depth perception as we age is likewise a complication.


One of the most dramatic symptoms of generalized musculoskeletal degradation in seniors is a loss of bone density. Osteoporosis is an issue for both sexes: 50 percent of women and 20 percent of men will suffer a spinal fracture in their lifetime due to osteoporosis and vertebral fractures are particularly prevalent in men aged 60 to 74.


While osteoporosis is markedly under diagnosed, its impact on seniors and their ability to maintain an active and mobile lifestyle should not be under- estimated. Bone mineral density loss begins after the age of 45, and approximately 90 percent of older adults show symptoms of disc degeneration. Aside from advanced age, risk factors include low body weight and height, smoking, three or more glasses of alcohol/day, the presence of risk factors for falls (such as stairs in the home), and a sedentary lifestyle.


Physical and occupational therapists designing and implementing programs for seniors need to be well aware of the risk factors and needs specific to this age group and understand how to structure a customized, efficient, and safe program that works with these issues.


Not-So-Fringe Benefits

The research-backed health benefits of high-intensity exercise and physical therapy programs for seniors are increasingly well documented, and new evidence continues to emerge outlining the profound benefits that these regimes can convey. While the benefits are many, and include things like preventing strokes and delaying the onset of diabetes, some of the most dramatic improvements can be seen in terms of patient strength and mobility.


The bone response to exercise, specifically weight-bearing and high intensity resistance training, includes increases in bone mass, bone size, and bone microarchitecture with corresponding decreases in the bone mineral density loss that occurs gradually after the age of 40 and in the number of osteoporotic fractures. For subjects between the ages of 50 and 70, one year of exercise had a positive effect on the following risk factors for osteoporosis: bone mineral density, muscle mass, muscle strength, and dynamic balance. Participants also reported notable increases in overall physical activity level. What is especially remarkable is the fact that no other intervention has been demonstrated to have this kind of effect on so many systems simultaneously.


Programs and Strategies

With the potential benefits so significant, it is all the more important to design a program that addresses the specialized therapeutic needs of vulnerable seniors. A true specialty, there are specific guidelines, standards, and exercises that need to be adhered to. While the specifics of any senior-focused physical therapy program should be put together by a Certified Exercise Expert for Aging Adults (CEEAA) or other therapist experienced in geriatric therapy techniques and strategies (therapists will factor in a patient’s age, diagnosis, and individual circumstances, including specific prescriptive remedies for individual priorities), there are certain key similarities that every effective and efficient program shares.


For physical therapists, the three primary areas of focus are strengthening, improving stability and balance, and increasing flexibility. All of those components together are essential; no single element is more important than the next. The types of exercises that are supported by cutting-edge research as being most effective in building balance and strength include dynamic balance exercises (such as standing on one foot, using the arms to catch some- thing, and reaching above the head to “clean a window”). The goal is to work on specific movements as the patient is balancing. Exercises that feature a combination of strength, flexibility, and balance work will be the most protective against falling and effective in addressing immobility.


The other key is the intensity of the workouts. High intensity, or at least moderate intensity, physical therapy is essential. If you do not stress the system enough, you will not achieve the necessary physiological change. Geriatric therapists understand that they need to use enough resistance and intensity to achieve and maintain long-term, life-changing results.


Keeping it Moving

While there is a great deal of emerging research in this area, the current consensus is that it takes at least 50 hours of an activity to manifest a significant improvement or a noteworthy physical change. Additionally, the current recommendation from the American College of Sports Medicine is that patients should strive for a minimum of 150 minutes of exercise per week to optimize results.

Taking into account that Medicare only covers 15 total hours of physical therapy for seniors per year, all while many more hours are clearly needed to create and sustain a lasting change, it is up to physical therapists to educate and arm their clients with the necessary knowledge and resources to continue working on the successes they have built in the sessions outside of the clinic’s four walls.


Therapists should develop and guide the implementation of a home exercise program to complement the therapeutic sessions, ensuring that clients understand how to safely practice and complete beneficial exercises at home. These programs can also address and improve the client’s physical environment, including a home evaluation and modification tips to reduce external falling risks.


Strong home exercise programs should also help connect seniors with safe, effective, and accessible community-based programs to help them maintain the active and healthy lifestyles they have built. Some clinics may offer supervised gym time, in which clients can utilize the firm’s equipment on their own time for a fee. Many community centers also offer activities for seniors such as gentle yoga, walking groups, or water aerobics that can be great supplements to their existing program. Therapists can help their client identify what they like and what works best for their schedules.


When all the elements of a well-rounded physical therapy program for aging seniors are combined, the results are not only dramatic; they, quite literally, can be a lifesaver.


Polly Swingle is co-CEO and lead physical therapist at Livonia, Mich.-based The Recovery Project, a provider of aggressive, focused and effective physical and occupational therapy for people with traumatic brain and spinal cord injuries, and other neurological disorders. Polly is a Geriatric Certified Specialist, a Certified Exercise Expert for Aging Adults (CEEAA) and has more than 25 years of physical therapy experience.


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