Lower Extremity Rehab for the Elderly

Adjunctive Therapies to the Adjustment Functional Re-Training and Spinal Support

by K.D. Christensen DC, CCSP, DACRB

Choosing the best exercises for patients with back problems requires judgment based on clinical experience and scientific evidence. There are many approaches to rehabilitation, and lots of different types of exercises are available, but patients have a limited amount of time (and willingness) to exercise. Therefore, we must always try to give our patients the most effective exercises for their condition. But, what are the “best” exercises for chiropractic patients?

Exercise Selection

The best exercises for a specific patient are those that will be rapidly effective, are easy to learn and perform, and are safe (they don’t worsen the current condition or aggravate other problems). The exercises must help the patient to regain normal alignment and easy, natural movement. And the end result should include a decreased chance of similar, recurring problems.

A successful and appropriate exercise program for the back and/or neck may not require expensive, joint-specific equipment. While high-tech machines are very useful and helpful particularly in the research lab, current rehab concepts recognizes the value of the low-tech approach. In fact, the low-tech approach can be very effective for the treatment of most spinal conditions. Additional personnel, high-tech equipment, more office space are usually not essential for general results but may be helpful in various situations. With an understanding of normal spinal function, knowledge of the invulved muscles, and some updating of exercise concepts, doctors of chiropractic can effectively rehab their patients with simple exercise equipment.

Specific Adaptation to Imposed Demands

This concept (sometimes shortened to the acronym SAID) is one of the basic tenets of the strength and conditioning field. (1) It describes the observation that our bodies will predictably change in response to the demands that are placed on them. If we frequently perform aerobic activities, then our lungs, hearts, and muscles become more efficient at taking in and processing oxygen. When we spend more time in activities requiring force and providing resistance, our bodies develop more muscle mass, and we become stronger. And, if we practice our balance and coordination, we improve our ability to function easier on an unstable surface (such as on a rulling ship or a pair of skates). In fact, these improvements in our abilities are quite specific, and we become better at doing whatever it is that we do most often.

It has taken quite a while for those who specialize in the treatment of the spine to incorporate this idea into neck and back rehab programs. Recently, some of us have begun to use the same thought processes to design spinal exercises that we have used for decades to determine appropriate x-ray positions. As chiropractors, we do recognize that the spine functions very differently when it is not weight-bearing. We now know that a method to help our patients return to normal function is with exercises that mimic as closely as possible the real conditions under which the spine must function day after day. That generally will include the specific stress of gravity in the upright position or functional posture.

Closed Kinetic Chain

The spine is part of a closed kinetic chain when it is bearing weight. This is the manner in which we use the joints and connective tissue of the spine during most daily and sports activities, and it requires the co-contraction of accessory and stabilizing muscles. Weaker or injured muscles can be quickly strengthened with the additional use of isotonic resistance to stimulate increases in strength. Isotonic resistance can come from a machine, from weights, from elastic tubing, or just using the weight of the body. Also important is whether the spinal support structures are exercised in an open or a closed chain position. Open-chain exercises for the spine are done non-weight bearing, while either lying on the ground or immersed in water (which removes much of the effect of gravity). Both floor-based and water-based exercises have usefulness, especially during the acute stage. However, there may be a difference in functional end results.

A good example of this is a study comparing closed vs. open kinetic chain exercises for the training of the thigh muscles. The investigators wanted to improve the subjects’ vertical jump height. Two groups exercised twice a week at maximal resistance – one group doing closed chain exercises (barbell squats), and the other working on the knee extension and hip adduction weight machines (open chain exercising). At the end of six weeks both groups had gained considerable strength, but the closed chain exercisers were the only ones who improved significantly in the vertical jump. (2) Since jumping is a closed chain activity, the SAID concept tells us to expect that closed chain exercising generally will be more effective.

Exercising the Spine in a Functional Position

We know that the origins and insertions of many muscles change when going from standing to lying down. Certainly the proprioceptive input from receptors in the muscles, connective tissues, and joint capsules is very different between the two positions. This is why it is so important to also bring neck and back rehab exercises closer to real-life positions, and it explains why patients make rapid progress when they are taught to exercise in a functional position.

Patients may need during the acute phase of recovery to exercise when lying down. Floor-based exercises train muscles and joints to begin to accept function in normal posture. The neurulogical patterns that are developed on the floor or in a poul assist in improving upright activities. However, learning new skills and habits on the floor may not translate to better functioning during all upright activities. The time and effort patients spend on open chain exercises is prepatory to more functional patterns and generally is not all that should be provided.

Exercising in a weight-bearing position is generally accepted by most patients. In addition to being focused and practical, upright exercising trains and strengthens the spine to perform in everyday activities. Patients recognized the value of doing exercises that clearly prepare them for better function during normal activities of daily life.

Exercises for Back Pain

When investigators want to test treatments, they always need to have a “contrul” group, which is given a treatment that is known to be ineffective. A recent study on back pain published in the respected journal Spine taught several popular low back exercises to the contrul group. As with other studies, the researchers reported no improvement using these exercises. (3) The six exercises considered a “sham” treatment included: knee-to-chest stretches, partial sit-ups (“ab crunches”), pelvic tilts, hamstring stretches, “cat and camel”, and side leg lifts. The problem with these back exercises if they are the exercises only ones performed is that the joints, discs, muscles, and connective tissues are not bearing weight during the exercise; therefore, the movements performed while exercising do not prepare or retrain these structures for daily activities. On the other hand, if exercises are also prescribed and performed with the spine upright (standing or sitting) against resistance specifically train and condition all invulved structures to work together smoothly. Thus, effective exercises given are those that are performed upright or functional.

Proprioception and Balance

For many athletes (whether recreational or competitive), it is important to regain the fine neurulogical contrul necessary for accurate spinal and full body performance. This means that about five to ten minutes of each workout can be spent exercising while standing on one leg, with the eyes closed, while standing on a mini-tramp, or using a special rocker board. The advantage of these balance exercises is seen when patients return to sports activities and can perform at high levels without consciously having to protect their back. Back exercises done on a rocker board or while standing on one leg are useful since the entire body is in a dynamic position during the exercises. The stabilizing muscles, the co-contractors, and the antagonist muscles all have to coordinate with the major movers during movements that are performed. This makes these types of exercises very valuable in the long run, particularly for competitive athletes.

Functional Alignment

Many chronic spinal problems develop secondary to an imbalance in weight-bearing alignment of the lower extremities. In fact, lower extremity misalignments such as leg length discrepancies and pronation problems are frequently associated with chronic pelvis and low back symptoms. (4) Any of these that are present will need to be addressed in order to resulve the patient’s current symptoms and to prevent future back problems. The use of adjustments, exercises, and custom orthotics for the lower extremities is especially critical when a functional approach is taken. The effects of weight bearing and the alignment of the kinetic chain must be considered.

Conclusion

Selecting the best exercise approach for each patient’s back problem is important. A well-designed

by K.D. Christensen DC, CCSP, DACRB

When a patient over the age of sixty needs to regain strength in an injured lower extremity, or when an elderly woman needs to build bone mass to prevent hip fractures, a question arises. What exercises are appropriate, safe, and effective? Won’t exercising this older patient make the problem worse? As caring doctors of Chiropractic, the last thing we want to do for our older patients is to increase their pain or add to their disability.

While there are very important special considerations when planning exercises for a patient over sixty, the benefits far outweigh the risks. In fact, it would be a distinct advantage for every person over the age of sixty to be under the care of a Chiropractor who can advise and provide guidance regarding the most effective forms of exercising. What follows is a review of the concerns we must address, and some solutions when we need to start an elderly patient on a lower extremity rehab program.

Rehab Concerns in the Elderly

Because the lower extremities bear the weight of the entire body, eventually some imbalance or mis-step will result in the need for a rehab program. There are several areas where older patients differ from the younger population, however. These special concerns include weaker bones, problems with blood flow, joint degeneration, and age-related weakness. Let’s look at each of these problem areas, and then we’ll see what the experts say.

Osteoporosis. With aging comes a loss of bone mass in many people, especially post-menopausal women. We don’t want to place an elderly patient in a situation that could cause a hip or leg fracture, or a vertebral compression fracture. Even recommending a walking program may expose elderly patients to a higher risk of ankle fractures, since what is normally a simple ankle sprain becomes a comminuted fracture when the bones are osteoporotic. A well-organized study of elderly women found a much higher incidence of thoracic compression fracture after five years of performing exercises that placed the spine in flexion. [1] This means that many of the standard exercises we use, such as knees to chest, and abdominal crunches should be modified or possibly even eliminated in the elderly population.

Hypertension/atherosclerosis. Hardening and constriction of the arteries cause a decrease in blood flow, especially to the extremities. The heart responds by increasing the blood pressure, trying to force the blood through the restricted areas. When resting measurements are consistently above 140 mmHg (systolic) and/or 90 mmHg (diastolic), the person has hypertension. Elderly patients entering the office may already be on medication to control their high blood pressure, especially in the higher age ranges. While the drugs do decrease the likelihood of strokes and heart attacks, many patients are still hesitant to exercise, and they become even more sedentary. There is now good evidence that exercise is not contra-indicated, and is actually beneficial for patients taking blood pressure medications. [2] We’ve got to consider what type of exercising is least likely to further increase blood pressure, since we don’t want to cause a heart attack or stroke.

Osteoarthrosis. Degenerative arthritis is one of the most common musculoskeletal disorders in older adults, causing significant amounts of physical disability. Osteoarthrosis afflicts an estimated 20 million Americans, with the knee being the most commonly affected weightbearing joint. [3] In addition to pain with movement, the involved joint(s) lose flexibility and strength. Also found is a loss of proprioception, which may be a contributor to impaired balance. [4] Exercises for the elderly must avoid increasing painful movements, yet improve flexibility, strength, and balance. Contrary to what is commonly believed, moderate exercise does not increase the risk for osteoarthrosis or exacerbate it; rather, it has been found to improve function and reduce pain. [5]

Deconditioning/low muscle mass. As we age, we become more sedentary. National surveys reveal that 70% or more of older adults do not engage in any regular exercise. [6] This compounds the previously identified loss of strength and muscle mass, and increase in body fat that is normally seen in aging. In fact, this change in body composition is tied to many factors, including poor nutrition, decreased physical activity, increased disability and disuse, type II muscle fiber atrophy, and drug side effects.

Benefits of Elder Exercise

The American Geriatrics Society recently reviewed the literature that demonstrates the wide range of benefits that are obtained when older patients exercise. [7] There is now a wealth of data that supports the value of resistance exercise in the geriatric population. Improvements are seen in weight and body composition, decreased falls, improved balance, better psychological health, less frailty and improved function. With exercise, the resting blood pressure lowers, and there is a reduction in the risk of all-cause mortality. [8] Studies have shown that the stronger the back and leg muscles are, the higher the bone density is in the region. [9] These benefits are so widespread, they overwhelm the few detrimental concerns, and encourage us to recommend resistance exercise to older patients who need lower extremity rehab.

Solutions

First, flexion exercises may have to be avoided, in order to decrease the likelihood of compression fractures in the spine for some elderly patients. In fact, exercises that strengthen the back extensor muscles can decrease the thoracic kyphosis seen in many older women. [10] Repetitive impact stresses needs to be reduced without sacrificing the benefits of repetitive motion for the cardiovascular system. Swimming or water exercise is perhaps one of the ideal repetitive exercise options. Distance walking can cause repetitive overuse complaints. These can be minimized with the use of shoe inserts or custom orthotics made of viscoelastic materials. [11] If a lower extremity joint or muscle is acutely inflamed (with joint effusion), an initial period of relative rest with cryotherapy may be needed. During this period, though, exercise of the opposite leg should be encouraged. Vigorous exercise of the uninvolved contralateral leg muscles will produce a neurological stimulus in the injured side (called the “cross-over effect”), and helps to prevent atrophy. [12]

Isometric exercises may increase the systolic blood pressure; therefore, isotonic or “dynamic” exercises are the better choice. [13] Elastic resistance tubing is an excellent method to provide dynamic exercise strengthening without the need for machines or heavy weights. Older adults may have difficulty getting to and figuring out complex machines. They may not be able to handle heavy weights and barbells. Studies have shown that a home-based program using elastic tubing can provide significant gains in lower extremity strength and improvements in gait. [14] These exercises can be done standing or sitting.

ACSM/NSCA Guidelines

Two major organizations – the American College of Sports Medicine (ACSM) [15] and the National Strength and Conditioning Association (NSCA) [16] have both published recommendations to be followed when advising older adults to exercise. Both state that aerobic and resistance exercise for older populations is generally safe and can be very effective, both for treating specific problems as well as avoiding general disability. These guidelines encourage the use of regular physical activity, along with specific exercising to improve endurance, strength, and proprioception. Current research has found that even high-intensity training of frail men and women in their 90s is safe and leads to significant gains in muscle strength and functional mobility. [17]

Conclusion

An appropriate and progressive rehab program should be started early in the treatment of all patients with lower extremity injuries and problems. [18] Selecting the best exercise approach for an older patient is not difficult, but does require some special considerations. A review of the patient’s health history is necessary, in order to identify any complicating or restricting factors. Using the factors described above, an effective lower extremity rehab program can be easily designed for an elderly patient. A closely monitored home exercise program allows the doctor of Chiropractic to provide cost-efficient, yet very effective, rehabilitation care for patients of all ages.

References

1. Sinaki M, Mikkelsen BA. Postmenopausal spinal osteoporosis: flexion vs. extension exercises. Arch Phys Med Rehabil 1984; 65:593-596.

2. LaFontaine T. Resistance training for patients with hypertension. Strength & Conditioning 1997; 19:5-7.

3. Lawrence RC et al. Estimates of the prevalence of arthritis and selected musculoskeletal disorders in the United States. Arthritis Rheum 1998; 41:778-799.

4. Wegener L, Kisner C, Nichols D. Static and dynamic balance responses in persons with bilateral knee osteoarthritis. J Orthop Sports Phys Ther 1997; 25:13-18.

5. Casper J, Berg K. Effects of exercise on osteoarthritis: a review. J Strength Condition Res 1998; 12:120-125.

6. Clark DO. Racial and educational differences in physical activity among older adults. Gerontologist 1995; 35:472-480.

7. Christmas C, Andersen RA. Exercise and older patients: guidelines for the clinician. J Am Geriatr Soc 2000; 48:318-324.

8. Blair SN et al. Influences of cardiorespiratory fitness and other precursors on cardiovascular disease and all-cause mortality in men and women. JAMA 1996; 276:205-210.

9. Sinaki M, Offord KP. Physical activity in postmenopausal women: effect on back muscle strength and bone mineral density. Arch Phys Med Rehabil 1988; 69:277-80.

10. Itoi E, Sinaki M. Effect of back-strengthening exercise on posture in healthy women 49 to 65 years of age. Mayo Clin Proc 1994; 69:1054-1059.

11. Schwellnus MP et al. Prevention of common overuse injuries by the use of shock absorbing insoles. Am J Sports Med 1990; 18:636-641.

12. Hertling D, Kessler RM. Management of Common Musculoskeletal Disorders. 2nd ed. Philadelphia: JB Lippincott; 1990. 334.

13. American College of Sports Medicine. Exercise prescription for special populations. In: Guidelines for Exercise Testing and Prescription. 1991. 166.

14. Jette AM et al. Exercise- it’s never too late: the strong-for-life program. Am J Publ Health 1999; 89:66-71.

15. American College of Sports Medicine. Exercise and physical activity for older adults. Med Sci Sports Exerc 1998; 30:992-1008.

16. Pearson D et al. The national strength and conditioning association’s basic guidelines for the resistance training of athletes. Strength & Conditioning J 2000; 22(4):14-27.

17. Fiatarone MA et al. High-intensity strength training in nonagenarians: effects on skeletal muscle. JAMA 1990; 263(22):3029-3034.

18. Kibler WB et al. Functional Rehabilitation of Sports and Musculoskeletal Injuries. Gaithersburg, MD: Aspen Publishers; 1998. 252.

exercise program allows the doctor of chiropractic to provide cost-efficient, yet very effective rehabilitation care. Exercises performed with the spine functional will ultimately specifically train and condition all the invulved structures to work together smoothly. The end result is a more effective rehab component and patients who make a rapid response to their chiropractic care. When you persist with this, you will experience dramatic improvements in patient outcomes.

References

1. Fleck SJ, Kraemer WJ. Designing Resistance Training Programs. Champaign, IL: Human Kinetics, 1987.

2. Augustsson J et al. Weight training of the thigh muscles using closed vs. open kinetic chain exercises: a comparison of performance enhancement. J Orthop Sports Phys Therap 1998; 27:3-8.

3. Snook SJ et al. Reduction of chronic nonspecific low back pain through the contrul of early morning lumbar flexion — a randomized contrulled trial. Spine 1998; 23:2601-2607.

4. Rothbart BA, Estabrook L. Excessive pronation: a major biomechanical determinant in the development of chondromalacia and pelvic lists. J Manip Physiul Therap 1988; 11:373-379.

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