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Physical Therapy for Older Adults With Arthritis: What is Recommended?: Future Perspective
Thursday, 20 May 2010 07:26

From International Journal of Clinical Rheumatology

Maura Daly Iversen

Posted: 05/12/2010; Int J Clin Rheum. 2010;5(1):37-51. © 2010 Future Medicine Ltd.

Abstract

With the exponential growth of the aging segment of the population, physical therapy clinics are treating larger proportions of patients with arthritic conditions. Arthritis is a leading cause of functional restrictions and disability due to its associated pain, inflammation, cardiovascular and pulmonary involvement. These symptoms overlaid upon normal age-related declines in the musculoskeletal, neuromuscular, integumentary and cardiopulmonary systems place older adults with arthritis at higher risk of disability and loss of independence. Physical therapy interventions are recognized as an integral component of arthritis management and their benefits have been well documented. This article reviews the common findings of the physical therapy examination and evidence for physical therapy interventions for select arthritic conditions.

Introduction

Arthritis and musculoskeletal disorders are widespread and may result in joint pain, soft tissue contracture, restrictions in joint movement and activities of daily living, deformity, disability[1] and, in some instances, death.[2] Physiologic manifestations of arthritis, such as joint capsule thickening, inflammation, muscle atrophy and reduced cardiopulmonary reserve, are exacerbated with physical inactivity and may be compounded with side effects of pharmacotherapy. Unfortunately, approximately 70% of older adults in the USA report no regular exercise and among older adults with arthritis, the rates of leisure time physical activity are 7% lower than their healthy counterparts.[3]

There are more than 100 rheumatic conditions, of which the most common form is osteoarthritis (OA). Osteoporosis may be present at any age, but is more prevalent in older adults. Polymyalgia rheumatica (PMR) presents with advancing age, while ankylosing spondylitis (AS) often presents early in life. Diseases such as systematic lupus erythematosus (SLE) and rheumatoid arthritis (RA) may present early (patients aged in their 30s and 40s) or have a late onset (age of 55 years and older). The systematic and local manifestations of these conditions are compounded by the normal aging process and influence the physical therapy management of older adults with arthritis.[2]

 

Normal Changes with Aging

In brief, changes with aging are evident across all systems of the human body and produce concurrent changes in physical performance over time. In the musculoskeletal system, muscle force production reaches its peak in the second and third decades of life and declines with age. Loss of motor units and reduction in muscle mass are associated with changes in protein synthesis and mitochondrial enzyme activity, leading to decreased strength.[4] Neurosensory changes result in diminished proprioception, disturbances in balance, reduced response to external challenges and increased risk of falls. In addition, cardiovascular and pulmonary systems become less efficient, resulting in declining stroke volume, vital capacity and exercise performance. Thus, older adults perform activities of daily living at a higher percentage of their physiologic reserve. However, these changes can be attenuated with exercise. A recent systematic review of 13 studies of exercise on musculoskeletal function in healthly older adults[5] reported strong evidence for the use of resistance training (three to four sets at 60–80%, one repetition maximal force production) for improving strength and muscle mass among healthy older adults. Among persons with arthritis, these recommendations require modifications to adjust for variations in physiologic condition and response to exercise, especially in light of the changes in physiologic reserve and function.

Physical Therapy Interventions & Management

Physical therapists are licensed healthcare professionals who provide interventions to address the prevention, diagnosis and treatment of movement dysfunctions and to improve physical health and function.[6] In the USA, physical therapists earn a university degree prior to matriculating into either a professional master or doctoral degree program. This level of education is not the norm worldwide. In some countries, physical therapy education is offered at the bachelor's level. While educational requirements vary across the globe, internationally the profession of physical therapy is evolving and educational requirements for programs are advancing.

Physical therapists provide interventions, such as therapeutic exercise, joint mobilization, physical modalities (e.g., heat, cold, electrical stimulation and ultrasound), gait training, assistive devices and orthotics, and combine these interventions with behavioral strategies and patient education to promote self-management and to maximize function and independence.[6] Interventions are individualized based upon a comprehensive physical examination and current pharmacologic management. Knowledge about the potential side effects of medications, as well as the latency period to effectiveness of medications, is essential when designing the intervention to ensure patient comfort and safety and to appropriately advance the regimen. Using a collaborative model of practice, physical therapists work with their patients to establish goals to decrease pain, maximize joint mobility, increase muscle strength, maintain and improve flexibility and aerobic capacity, and prevent functional loss. The following sections briefly describe the focus of the physical therapy assessment and the evidence for effectiveness of physical therapy interventions for older adults with arthritis.

Adherence to Exercise

Exercise and physical activity require active participation of patients and, as such, their effects are proportional to the patient's level of adherence. The literature demonstrates that adherence to short-term supervised exercise programs, defined as programs that last anywhere from 1 to 12 months, ranges from 68 to 93%. Long-term adherence rates to exercise that requires more extensive lifestyle changes are lower, in the range of 25–50%. With advancing age, adherence to exercise diminishes and is lower still among older adults with arthritis. Recent studies have examined factors associated with exercise adherence among persons with chronic pain[66] and arthritis (Table 2).[67–69] Factors associated with exercise adherence include internal factors, such as self-efficacy, prior experience with exercise, attitudes, beliefs and expectations regarding the benefits of exercise for arthritis, as well as external factors, such as providers' beliefs and attitudes toward exercise for arthritis, limited access, cost and time.[66–70] Greater frequency of exercise may be less influential than higher intensity as higher intensity exercise may result in short-term muscle soreness and stiffness.

To promote adherence physical therapy interventions and maximize outcomes of care, physical therapists should integrate patients' preferences for treatments, address patients' expectations of care, and attitudes and beliefs toward interventions. Goals for treatment should be established in small increments that are attainable in the established timeframe. Clinical discussions focusing on the benefits of exercise, how to address potential barriers to exercise and modify the program promote adherence. The use of an exercise log is helpful to demonstrate progress and to record difficulties with specific exercises. Social support for exercise has also been demonstrated to increase adherence, and so it is important to encourage patients to engage the assistance of a significant other to motivate them to exercise and to link patients with community-based programs.[71]

Self-management programs that target patient's beliefs, attitudes and self-efficacy for managing arthritis have proven to be effective in improving function, reducing disability and maximizing quality of life.[72–74] While physical therapists educate patients about self-management as part of their intervention, there are a plethora of community-based and internet-based, well-tested, self-management programs available to patients. The Stanford Arthritis Self-Management Program is the most well studied and successful program for persons with arthritis with demonstrated improvements in symptoms and function and reduced healthcare utilization.[72–74] Such programs are useful to augment the benefits of treatment and increase long-term compliance with management recommendations.

Table 1. Onset, pathology, physical examination findings and recommended physical therapy interventions for systematic lupus erythematosus, rheumatoid arthritis, osteoarthritis, osteoporosis, ankylosing spondylitis and polymyalgia rheumatica.

ConditionPathology and onsetPhysical findingsPhysical therapy interventions
Systemic lupus erythematosus Systemic inflammation of multiple organ systems;
Onset: early or late (>55 years)		 Fatigue and malaise;
Reduced cardiovascular reserve;
Arthalgias uncommon;
Coronary artery disease		 Fatigue management;
Progressive aerobic exercise (60–80%) to enhance endurance, frequent monitoring of vital signs during exercise;
Dynamic strengthening exercises of moderate intensity (two to three times per week)
Polymyalgia rheumatica Myositis and vaculitis;
Onset: seventh decade of life		 Proximal muscle pain and stiffness;
Stiffness worse in the morning and with physical inactivity;
Swelling of distal hand joints atypical;
Fatigue – primary complaint		 Active disease:
  • Active and passive stretching exercises
  • Activity modification
  • Patient education (assistive devices if needed)
Stable disease:
  • Strengthening exercises (eight to ten reps) especially to shoulder and hip girdle muscles. Dynamic balance and core stability exercises
  • Aerobic exercises using 60–80% of age-predicted heart rate as standard or modify based on individual cardiovascular health. Progress as tolerated
  • Education about fall risk and strategies to reduce falls and increased physical activity
Osteoporosis Deterioration of bone leading to decreased bone mass and fragility;
Onset: any age in presence of corticosteroids and poor nutrition;
Prevalence increases with age		 Reduced stature;
Postural changes including decreased lordosis, reduced flexibility of the shoulder and hip girdle muscles;
Decreased aerobic capacity;
Dynamic instability may be present		 Strengthening exercises with low and moderate resistance depending on physical examination findings;
Low impact aerobic exercise, avoid high-impact exercises in frail adults;
Core stability and functional exercises;
Balance activities; Flexibility and postural exercises for shoulder and pelvic girdle;
Education about fall risk and strategies to reduce falls and increased physical activity
Rheumatoid arthritis Synovitis;
Vasculitis;
Onset: early or late (>55 years)		 Bilateral and symmetrical polyarticular joint involvement;
Joint pain, inflammation;
Joint stiffness;
Contractures may be present;
Crepitus;
Fatigue often underappreciated;
Muscle weakness		 Acute exacerbation:
  • Active ROM exercises (two reps/joint/day)
  • Frequent rest to address fatigue
  • Orthoses and splints for supportive and neutral joint position
  • Isometric exercises (6-s hold, four reps)
Subacute:
  • Active ROM exercises: 8–10 repetitions/joint/day
  • Isometric exercises four to six contractions
  • Light resistance dynamic exercises (avoid if joints are unstable, in presence of tense popliteal cysts or internal joint derangement)
  • Aerobic exercise in pool or on land for 15–20 min (three times/week).
  • Cardiac evaluation is recommended. Establish heart rate parameters and use perceived rating of exertion scale
Stable disease:
  • As above, but increase aerobic activities
Osteoarthritis Cartilage degeneration;
Onset: insidious		 Stiffness and pain predominantly in large weight-bearing joints;
Joint malalignment present;
Weakness especially of quadriceps;
Joint instability/hypermobility;
Abnormal patella tracking with retropatellar pain		 Mild disease:
  • Active ROM exercises with daily activities, three to five reps of flexibility exercise and eight to ten reps of static exercises, each of 6-s duration)
  • Dynamic exercises, especially to quadriceps and hamstrings (eight to ten reps);
  • Low-impact aerobic activities (aquatic and bicycling) 20 min, three times per week
  • Balance activities (BAPS and tilt board), single-limb stance
Moderate:
  • Static and dynamic exercises – reduce to five reps, three to five reps of flexibility exercises
  • Low-impact aerobic exercises (aquatic, bicycling – 20 min, three times/week); balance and proprioception activities – bilateral
  • Use of cane or lateral heel wedge foot orthosis, neoprene knee sleeve
Severe disease:
  • Low- to no-impact aerobic exercises (aquatic)
Note: advise functional activities to keep moving, few to no reps of dynamic exercises; patient education is very important
Note: in patients with ligamentous laxity and malalignment, caution should be taken with prescribing quadriceps strengthening exercises; orthoses, crutches or walker
Ankylosing spondylitis Endethitis;
Onset: 15–30 years of age		 Stiffness and pain in axial spine, sacrum, sometimes involves hips and shoulders Flexibility and spinal mobility exercises, postural re-education, aerobic exercise to maintain pulmonary function

BAPS: Biomechanical ankle platform system; Rep: Repetition; ROM: Range of motion.
Adapted from [75].

[ CLOSE WINDOW ]

Table 2. Studies of adherence to exercise in patients with arthritis.

StudySubjects and form of arthritisInterventionResultsRef.
Iversen et al. (2004) 132 patients with RA (mean age: 58.4 years) and 25 rheumatologists None. Observational cohort Predictors of exercise behavior at 6 months were patients' past history of exercise (OR: 6.8; 95% CI: 3.1–15) and rheumatologists' current exercise behavior (OR: 0.26; 95% CI: 0.09–0.77). [68]
Wilcox et al. (2006) 68 persons with all forms of arthritis None. This was a focus group study to examine barriers, benefits of exercise Barriers to exercise included symptoms of arthritis, physical/environmental factors;
Facilitators: past positive experience with exercise, waning of symptoms		 [67]
van Gool et al. (2005) 206 overweight and obese persons with knee osteoarthritis The Arthritis, Diet, and Activity Promotion Trial 18-month diet counseling and exercise session 60.7% diet sessions and 53.2% of the exercise sessions attended. High attendance at diet sessions associated with not being married and low social participation (months 1–4). Exercising at home predicted high attendance to exercise sessions (months 5–18). High early attendance correlated with high later attendance [69]
Mayoux-Benhamou et al. (2008) 208 outpatients with RA Control: received booklet and usual care;
Treatment: 6-month multidisciplinary education with home exercise and guidelines for activity		 At 6 months, the treatment group showed greater adherence to exercise and physical activity (13 vs 1% and 28 vs 14%). No difference at 12-month follow-up.
Predictors of adherence were low activity level at baseline, less fatigue and stable mood state		 [70]
Medina-Miraplex et al. (2009) 34 individuals with neck or low back pain Received individual home exercise program by a physical therapist Factors change when pain or disabilities appear. Beliefs about illness and treatment are more likely when pain is present. When pain decreases patients consider perceptions about barriers, social support and physical environment [
 

Conclusion

The clinical manifestations and impact of arthritis is compounded by the natural changes of aging. Physical therapy interventions provide a comprehensive approach to the management of musculoskeletal conditions in older adults. While the benefits of all interventions have not been formally established, exercise and specific modalities have been demonstrated to improve patient-oriented outcomes. Initiated early and consistently, physical therapy aims to maximize function and independence and reduce impairments in older adults with arthritic conditions.

Future Perspective

With the changing demography and growth of persons aged older than 65 years, coupled with advancing in medical therapies, we will see a stronger emphasis on evaluative research on nonpharmacologic management of older adults persons with rheumatic conditions. While the evidence is accumulating for the effectiveness of exercise in managing arthritis symptoms and improving function and quality of life, further research is needed to examine the specific impact of exercise for older adults with arthritis and to document the impact of long-term adherence to therapy. Research is needed on the effectiveness of interventions for persons with PMR and for adults with late-onset RA and SLE. Physical therapy educational programs should include more information for therapists on the types and impact of arthritis to ensure proper management of all persons with arthritis, especially older adults.

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    Websites
    101. The National Osteoporosis Foundation. www.nof.org (Accessed on 7 July 2009)
    102. The National Center for Injury Prevention. www.cdc.gov/injury (Accessed July 21 2009)

    Papers of special note have been highlighted as:
    • of interest
    •• of considerable interest
 
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