Methods

The physician or rehabilitation team determines which methods of rehabilitation are appropriate. Most patients require some type of physical therapy. Leisure or recreational therapy is often appropriate for demented or institutionalized patients who need some exercise but not the specialized resources of physical therapy. Occupational therapy for the elderly usually consists of training in ADLs. Specific problems (eg, blindness, heart disease, stroke, hip fracture, leg amputation) may require specialized rehabilitation.

Physical Therapy

Before prescribing physical therapy, the physician ensures that the patient is medically stable and notes any cardiac, pulmonary, neurologic, or musculoskeletal limitations. Elderly patients may have several problems, and therapy must often be prioritized. After evaluating the patient, the physical therapist, working closely with the physician, develops and implements a prioritized treatment plan, then monitors it, adjusting goals and therapy as needed. Because caloric requirements are increased during rehabilitation, caloric intake must be increased accordingly to prevent weight loss and nutritional deficits.

Range-of-motion exercises: Several physical therapy techniques can help improve range of motion, which commonly becomes restricted after a stroke or prolonged bed rest. Restricted range of motion can cause pain, reduce functional abilities, and predispose patients to pressure sores.

Range of motion should be evaluated with a goniometer before therapy and regularly thereafter. In healthy elderly persons, the range of motion for certain joints is usually lower than would be normal for younger patients (see Table 28-2), but this age-related decrease does not usually prevent the elderly from being able to perform ADLs without assistance.

Exercises to increase range of motion are indicated for all elderly patients with restricted motion, unless functional deficits are profound. Range-of-motion exercises may be:

• Active, for patients who can exercise without assistance
• Active assistive, for patients whose muscles are too weak to exercise without assistance (and who also require strengthening exercises) or for patients who experience discomfort during joint movement
• Passive, for patients who cannot actively participate (see Figure 28-2)

Active-assistive or passive range-of-motion exercises must be performed very gently. Aggressive movements can easily damage joints with restricted motion or break osteoporotic bones. Movements producing severe pain should be avoided, although some discomfort may be unavoidable. If the affected joint is adjacent to an unfixed fracture, passive exercises should not be performed.

Before beginning therapy, the physical therapist must determine if restricted motion is due to tight ligaments and tendons or to tight muscles; if tight muscles are the cause, the joint can be stretched more vigorously. The affected joint must be moved beyond the point of pain, but the movement should not cause residual pain. Sustained moderate stretching is more effective than momentary forceful stretching. For sustained stretching, 5- to 50-lb (2.3- to 23-kg) weights with pulleys are applied for 20 minutes/day; manual (passive) stretching is time-consuming and fatiguing for therapists. Stretching is usually most effective and least painful when tissue temperature is raised to about 43° C (109° F).

Muscle-strengthening exercises: For the elderly, the purpose of these exercises is to strengthen muscles enough to perform a given function, not necessarily to regain normal strength for age. Many forms of exercise increase muscle strength; all involve progressively increased resistance. When a muscle is very weak, gravity alone is sufficient. As muscle strength increases, resistance is gradually increased--eg, when muscle strength becomes fair, manual or mechanical resistance (eg, weights) is added (see Table 28-3). In this way, muscle mass and strength are increased, and endurance is improved.

Proprioceptive neuromuscular facilitation: This technique promotes useful neuromuscular activity in patients with spasticity due to upper motor neuron damage; it enables them to feel muscle contraction and helps maintain the affected joint's range of motion. For example, in patients with right hemiplegia, strong resistance applied to the left biceps causes the right elbow to flex through contraction of the right (hemiplegic) biceps. The exact mechanism is not clearly understood, but reflex-related proprioception may be involved. Various techniques (eg, Brunnstrom, Rood, Bobath) are widely used.

Coordination exercises: These task-oriented exercises are for patients who need to improve coordination (eg, stroke patients). They involve repeating a meaningful movement that works more than one joint and muscle (eg, picking up an object, touching a body part). The goal is to improve motor skills to the premorbid level.

Transfer training: The patient's ability to transfer must be evaluated, and training provided as needed. Patients who cannot transfer safely and independently from bed to chair, chair to commode, or chair to a standing position generally require 24-hour attendants. Also, patients who cannot transfer safely have a high risk of falling, with risk of fracture or other injury. Such patients may require institutionalization.

Transfer training is particularly important after a hip fracture or stroke. The therapist must patiently and closely supervise the patient. The techniques used depend on whether the patient can bear weight on one or both legs, has sound balance, or has hemiplegia. Assistive devices can sometimes help. For example, persons who have difficulty standing from a seated position may benefit from a chair with a raised seat or a self-lifting chair.

Ambulation exercises: The purpose of these exercises is to improve the patient's ability to walk independently or be assisted by a person or device. Enabling the elderly to walk at the premorbid level is ideal, but enabling them to walk only a few steps (eg, to the toilet or a chair) is often sufficient.

Before starting ambulation exercises, some patients need to improve a joint's range of motion or muscle strength. If a muscle remains weak or spastic, an orthotic device (eg, a brace) may be necessary. Training may begin on parallel bars, especially if the patient's balance is impaired, and progress to walking with aids (eg, walker, crutches, cane). Some patients wear an assistive belt to help prevent falls. Balance training may also be useful. Persons assisting patients with ambulation should know how to properly support them (see Figure 28-3).

As soon as patients can walk safely on level surfaces, they can start training to climb stairs or to step over curbs if either skill is needed. Patients who use walkers must learn special techniques for climbing stairs and stepping over curbs. When climbing stairs, ascent starts with the better leg, and descent with the affected leg (ie, good is up; bad is down). Before the patient is discharged, the social worker or physical therapist should arrange to have secure handrails installed along all stairs in the patient's home.

General conditioning exercises: A combination of the exercises described above is used to counter the effects of debilitation, prolonged bed rest, or immobilization; to reestablish hemodynamic balance; to increase cardiorespiratory capacity; and to maintain range of motion and muscle strength.

Use of a tilt table: For patients with orthostatic hypotension due to paraplegia, quadriplegia, prolonged bed rest, or immobilization, a tilt table may be used to help reestablish hemodynamic balance. The patient, held in place with a safety belt, lies supine on a padded table with a footboard. The table is tilted manually or electrically; the angle is increased very slowly to 85°, if this angle can be tolerated, so that the patient is nearly upright. How long the position is maintained depends initially on the patient's continued tolerance, but it should not exceed 45 minutes. The procedure is performed once or twice daily. Effectiveness depends on the patient's disability and the duration of immobilization.

Treatment of Pain and Inflammation

Heat therapy: Heat increases blood flow and the extensibility of connective tissue; decreases joint stiffness, pain, and muscle spasm; and helps inflammation, edema, and exudates resolve. Heat therapy is indicated for acute and chronic traumatic and inflammatory conditions (eg, sprains, strains, fibrositis, tenosynovitis, muscle spasm, myositis, painful back, whiplash injuries, various forms of arthritis, arthralgia, neuralgia). Heat must be applied very carefully to elderly patients because skin sensation or cognitive capacity may be diminished, increasing the risk of burns. The intensity and duration of heat's physiologic effects are determined mainly by tissue temperature, the rate of temperature elevation, and the area treated. When heat does not work, cold can be applied.

Heat application may be superficial or deep. Hot packs, infrared heat, paraffin baths, and hydrotherapy provide superficial heat. Diathermy and ultrasound provide deep heat.

Hotpacks, the most common form of heat application, are available as cotton cloth containers filled with silicate gel. They are boiled in water, cooled to a temperature that does not burn the skin, and applied. Wrapping the packs in several layers of towels helps protect against burns. Contraindications include advanced heart disease, peripheral vascular disease, impaired skin sensation (particularly to temperature and pain), and significant hepatic or renal insufficiency.

Infrared heat is applied with a lamp, usually for 20 minutes/day. Contraindications are the same as those for hot packs.

A paraffin bath can be used to apply heat, usually to small joints. Wax heated to 49° C (120° F)--never > 54.4° C (> 130° F)--is applied by dipping or immersing (eg, a hand) or painting (eg, a knee or elbow) and then wrapping with a towel. Because the heating effect is relatively short-lived, infrared heat may be applied immediately afterward. Melted wax should not be applied to open wounds; it is contraindicated in persons allergic to paraffin.

Hydrotherapy, involving agitated warm water, may be used to apply heat or to enhance wound healing by stimulating blood flow and debriding wounds. A Hubbard tank (a large industrial whirlpool) with water heated to 35.5° to 37.7° C (96° to 100° F) is often used. Total immersion in water heated to 37.7° to 40° C (100° to 104° F) may also help relax muscles and relieve pain. For localized pain, the whirlpool and lowboy are used. A lowboy is a small whirlpool with one leg for support, which allows the patient to sit much closer to the water jets than a conventional whirlpool does. It is used primarily for an upper extremity.

Hydrotherapy is particularly useful in conjunction with range-of-motion exercises. Hydrotherapy has no contraindications. However, patients may become fatigued during treatment, and blood pressure may fall.

Short wave diathermy, although less effective than previously thought, is sometimes used to treat inflammation, pain due to urinary calculi, pelvic infections, and acute and chronic sinusitis. Contraindications include malignancy, hemorrhagic conditions, peripheral vascular disease, and loss of sensation. Caution: Short wave diathermy is also contraindicated in persons with nonremovable prostheses, electrophysiologic braces, or metallic implants (eg, bars, screws, plates), because the heated metal may absorb heat and cause a burn, and in persons with implanted devices (eg, pacemakers), because the devices may malfunction or be destroyed. No metallic substance should be in contact with the skin during the treatment.

Microwave diathermy is simpler and more comfortable to apply than short wave diathermy, and output measurement is more accurate. The heat it provides is deeper and produces less superficial skin damage because microwaves are selectively absorbed into tissues with high water content (eg, muscles). Despite its advantages, microwave diathermy has many adverse effects (eg, burns due to the heating of metallic implants, pacemaker dysfunction) and is not used as widely as short wave diathermy or ultrasound. Indications, contraindications, and precautions are similar to those for short wave diathermy.

Ultrasound involves the use of high-frequency sound waves, which penetrate deep into the tissue (4 to 10 cm [1.6 to 4 inches]) and produce thermal, mechanical, chemical, and biologic effects. This therapy may be used to treat limited range of motion caused by muscle shortening and fibrosis; skin or subcutaneous tissue scarring; bursitis, calcific bursitis, tendinitis, myositis, tenosynovitis, epicondylitis, and spondylitis; pain from postoperative neurofibromas (especially those embedded in scar tissue); myofascial pain syndrome, phantom pain, neuritis; sciatica and other forms of radiculitis; contusions; reflex dystrophies (eg, Sudeck's atrophy, causalgia, shoulder-hand syndrome); and chronic skin ulceration. Ultrasound is contraindicated in patients with ischemic tissue, hemorrhagic diathesis, malignancies, anesthetized areas, or areas of acute infection. Also, it should not be applied over the eyes, brain, spinal cord, ears, heart, reproductive organs, brachial plexus, or healing bone.

Cold therapy (cryotherapy): Application of cold may help relieve muscle spasm, myofascial or traumatic pain, acute low back pain, and acute inflammatory lesions as well as help induce local anesthesia. The choice between heat or cold therapy is often empiric; however, for acute pain, cold therapy seems to be more effective than heat therapy.

Cold may be applied locally using an ice bag, a cold pack, or volatile fluids (eg, ethyl chloride), which cool by evaporation. The spread of cold on the skin depends on the thickness of the epidermis, the thickness of underlying fat and muscle, the water content of the tissue, and the rate of blood flow. Care must be taken to avoid tissue damage (ie, frostbite) and general hypothermia, especially in patients with diminished skin sensation or mental capacity. Cold should not be applied over poorly perfused areas.

Electrical stimulation: Denervated skeletal muscle and innervated muscle that cannot be contracted voluntarily can be stimulated electrically to help alleviate or prevent disuse atrophy and muscle spasticity, especially in patients with hemiplegia due to a cerebrovascular accident, with traumatic paraplegia or quadriplegia, or with peripheral nerve injury. The unipolar technique involves placing a large dispersive electrode on a distant part of the body and a smaller active electrode on the muscle being treated. When this technique produces the desired contractile response, it is preferred to the bipolar technique because it uses a lower current. The bipolar technique involves placing two small electrodes over the ends of the muscle. This technique is useful for severely degenerated muscles caused by gross anatomic or physiologic interruption of the nerve supply and for unusually high skin impedance (eg, when edema exists in the area being treated).

Usually, 10 to 20 muscle contractions per session are sufficient for both the unipolar and bipolar techniques. Overstimulation may cause muscle fatigue and may eventually cause muscle damage. Electrode burns may result from inadequate skin contact or too much current. Areas of skin in contact with electrodes should be closely monitored to prevent burns, especially in elderly patients, who may be prone to burns because of age-related decreases in skin sensation or mental capacity. Electrical stimulation is contraindicated in patients with advanced cardiac disease, because it may precipitate an arrhythmia, and in patients with a pacemaker, because it may interfere with its functioning. Electrical stimulation should not be applied over the eyes.

Transcutaneous electrical nerve stimulation (TENS), which uses low current at low-frequency oscillation, is particularly useful for chronic back pain, rheumatoid arthritis, sprained ankle, contusion, postherpetic neuralgia, causalgia, phantom limb syndrome, and trigger points. It may also promote callus formation in a nonunited fracture. TENS may be applied several times daily for 20 minutes to several hours, depending on the severity of pain. Often, patients are taught to use the TENS device, so that they can decide when to apply treatment. The device produces a gentle tingling sensation without increasing muscle tension.

TENS is generally well tolerated but its effectiveness varies greatly. Advantages include the unit's small size, portability, and low cost. TENS is contraindicated in persons with advanced cardiac disease or a pacemaker because it may precipitate an arrhythmia. It should not be applied over the eyes. If the electrodes are improperly placed on the skin, erythema may develop.

Traction: Spinal traction is used to overcome extrinsic muscle spasm and to keep bony surfaces aligned while fractures heal. A weight and pulley system, the patient's weight, or manual or motorized force can be used. The force may be applied continuously or intermittently.

Cervical traction is often used for chronic neck pain due to cervical spondylosis, disk prolapse, whiplash, or torticollis. A 5- to 10-lb (2.5- to 5-kg) weight is used. Some advocate heavier weights, but sustained traction with > 20 lb (> 10 kg) for more than a few minutes is poorly tolerated; motorized intermittent rhythmic traction is generally well tolerated. Generally, hyperextension of the neck should be avoided, because it may increase root compression in the neuroforamina.

Lumbar traction is rarely used, although it is sometimes recommended for treating patients with painful lumbar osteoarthritis or spondylolisthesis. Its value in treating acute discogenic pain is debated, and it puts the elderly at risk of developing a secondary disability because it requires prolonged bed rest. For patients with severe osteoporosis or osteoarthritis, traction must be carefully and gently applied.

Massage: Massage may relieve pain, reduce swelling and induration due to trauma (eg, fracture, joint injury, sprain, strain, bruise, peripheral nerve injury), and mobilize contracted tissues. Massage may be appropriate for patients with low back pain, arthritis, periarthritis, bursitis, neuritis, fibrositis, hemiplegia, paraplegia, quadriplegia, multiple sclerosis, or cerebral palsy. It should not be used to manage infections or thrombophlebitis.

Acupuncture: Thin needles are inserted through the skin at specific body sites, frequently far from the site of pain. These needles, made of stainless steel, gold, or platinum, are twirled rapidly and intermittently for a few minutes, or a low electric current is applied through the needles. Although the mechanism of action is not fully understood, many practitioners believe that acupuncture stimulates endorphin production, generating analgesic and anti-inflammatory effects. The value of this technique is debated.

Acupuncture should be performed only by trained persons. Sterilized or new needles must be used to avoid infection.