3.3 MSK considerations for the Elderly

What are some factors that change biologically with age

discs

ligaments

joint capsules

articular cartilage

muscle

bone density

What are the disc impairments

• decreased water in nucleus

• increased fibroses of annulus

What do the disc impairments lead to 

flatter less resilient disc 

Why do the discs have decreased water in the nucleus

dehydration

What are some pathologic changes due to aging

neurologic disease

arthritis

cardiopulm complications

postural hypotension

What can bone on bone diseases  lead to

potential bone spurring

What can cause the bone on bone disease

changes in spinal curvature

What does impingement cause

numbness

tingling

loss of light touch sensation

long term effects of impingement

parathesis or paralysis

Once impingement leads to weakness, what treatments are available

may have to consider surgery

What can impingements do changes in posture lead to

balance issues (changed COG)

What may help with postural changes effect on fall frequency

assistive devices

Typical posture for elderly populations

head forward

thoracic kyphosis

lumbar lordosis

hip flexion

knee flexion

What issues can head forward posture lead to

cervical pain

What issues can increased thoracic kyphosis posture lead to

respiration/thoracic wall movement

scapular resting position (weakening in postural mm)

common postural changes

hip flex

knee flex

valgus/varus

decreased/increased lumbar lordosis

loss of height

What can decreased lumbar lordosis lead to

arthritis

What can increased lumbar lordosis lead to

weakened abs

What is an intervention for postural changes

extension (back bends, cervical retraction, chest puffing, prone on elbows, scapular retraction)

age related changes to strength

Decreased number and size of muscle fibers (strength)

decreased rapid muscle force exertion (power)

age related changes to pain

decreased ability to localize pain

decreased production/use of enkephalin

decreased report of pain due to social pressures

age related changes to hypokinesis

more sedentary lifestyle (sitting in flexed posture in recliner)

What type of muscle fibers are present in elderly

decreased Type 2, increased type 1

CV strength impairments

inefficiently leads to poor nutrient exchange

neuromuscular junction strength impairments

contract inefficiently

Other strength impairments

pathology (Parkinson’s/strike)

MSK strength impairments

swelling, joint distension

What is joint distension

enlargement of the joints causing difficulty in completing activities

Interventions for strength

increase activity levels

modalities and anti-inflammatory medication

How can exercise be beneficial

increases blood flow to the mm

improve nerve conduction velocity (reaction times)

What should be included in the exercise process

warm up/cool down

functional activities

circuit training

strength training with focus on spinal alignment

isometric recommendations for strengthening

• near max effort

• 6-10 sec holds

• 5-10 reps

• 10 sec rest

• 3xday, 5 weeks max

isotonic recommendations for strengthening

• determine 1RM

• exercise 60-800% 1RM

• 3 sets of 8-10 reps

• 1-2 min rest

• 3xweek, 8 weeks min

What can lead to flexibility impairments

decrease in elastin and collagen

tendons and ligs become more rigid

less responsive to length changes

hypokinesis

flexibility interventions

slow, prolonged stretching

maintain/gain functional range

encourage frequent activity

How often should a pt change stretching positions

every 15-20 mins

Pain considerations

rate pain

point to exance location of pain

Effective pain management techniques

TENS

visual imagery (go to your place/where do you wanna get back to)

relaxation

coordination with MD for medications

Pain education

purpose of pain mgmt

scheduling in consideration of therapy sessions (timing of dose)

important of communicating with healthcare team about pain

importance of activity in pain mgmt

NIH definition of osteoporosis

a systemic, skeletal disease characterized by low bone mass and micro architectural deterioration of bone tissue, with constant increase in bone fragility and susceptibility to fracture

What test is taken to determine osteoporosis

BMD or DEXA

WHO definition of osteopenia

BMD between 1 and 2.5 SDs below adult peak mean without evidence of fractures

WHO definition of osteoporpsis

BMD at least 2.5 SDs below adult peak mean without evidence of fractures

WHO definition of severe osteoporosis

BMD more than 2.5 SDs below adult peak mean with history of 1 or more fractures

Compare men and women bone density levels

men’s are always higher and have greater increase in 20s

women drop drastically with menopause

men progressively decrease

risk factors for osteoporosis

• sex

• age

• race

• family history

• tobacco

• lifetime exposure to estrogen

• meds

• calcium deficiency

• sedentary lifestyle

• alcoholism

• depression

Medication treatments for osteoporosis

Hormone replacement therapy (estrogen)

selective estrogen receptor modulators

biphosphonates

calcitonin

What is calcitonin

hormone that regulates bone metabolism

What are the effects of calcitonin

reduced bone resorption and may slow bone loss

What are the effects of biphosphonates (Fosamax; Didronel; Actonel)

inhibit bone breakdown/bind permanently to to bone surfaces

limit osteoblast activity

What is selective estrogen receptor modulators

synthetic drugs mimic estrogen’s beneficial effects on bone density

What are the effects of selective estrogen receptor modulators (Raloxifene)

block the effect of estrogen on breast and uterine tissue

What are the effects of hormone replacement therapy (estrogen)

side effects and increase the risk of breast / uterine cancer

Essential exercise for osteoporosis

postural alignment

high impact strengthening

WB exercises

How are extension exercises beneficial to osteoporosis

reduce the incident of spine fx reoccurrence

How are high impact exercises beneficial to osteoporosis

better at increasing BMD than low impact activities

stronger m=stronger bones

How are WB exercises beneficial to osteoporosis

retains more bone mineral than NWB

What are the effects of swimming on BMD

none

What are the effects of walking on BMD

protect against further loss

What are the effects of weight training on BMD

increase

What are the effects of running on BMD

increase

What occurs when spinal compression fxs arise from osteoporosis

pain management

safe transitional movements

orthosis

What are the orthoses typically used for spinal compression fxs due to osteoporosis

lumbosacral corset, jewett brace

What are the common fx associated with osteoporosis

hip and vertebral bodies

When would semirigid braces be used when spinal conpression fxs are present

when the spinal canal is involved

What is a Kyphoplasty

a balloon catheter is inserted into a thoracic vertebral body, then filled with cement to regain normal size

What is a vertebroplasty

a balloon catheter is inserted into a lumbar vertebral body, then filled with cement to regain normal size

What is the point of a kyphoplasty/vertebroplasty

help relieve pain

PT interventions in the acute phase following a compression fx

pain mgmt with modalities

bedrest (possibly)

TherEx

PT interventions in the sub-acute phase following a compression fx

walking program

TherEx

What TherEx treatments are focused on in the acute phase following a compression fx

addressing postural awareness

What TherEx treatments are focused on in the Sub- acute phase following a compression fx

strengthen abs/back ext/scapular retractors

What type of activity do we want to avoid during the Sub-acute phase following a compression fx

lifting >10 lbs

flexion

precautions to PT interventions post compression fx

• MD guidelines

• Exercise tolerance

What is the activity pyramid for people over 60

What are the key education points to give elderly pts

• sit as little as possible

• 2-3xwk, do yard/house work and strengthening

• 3-5xwk do aerobic activity and swim/golf/tennis

• every day, walk more at home/take stairs/park further from store