Treatment Strategies for the Geriatric Athlete An Evidence Based - - PowerPoint PPT Presentation

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Treatment Strategies for the Geriatric Athlete An Evidence Based - - PowerPoint PPT Presentation

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Treatment Strategies for the Geriatric Athlete An Evidence Based Approach Andrew Morgan, PT, DPT, MBA, COS C 1 Introduction Bachelor of Science in Education, May 1999 Master of Business Administration, May, 2005 Doctor

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Treatment Strategies for the Geriatric “Athlete”

An Evidence‐Based Approach

1

Andrew Morgan, PT, DPT, MBA, COS‐C

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Introduction

  • Bachelor of Science in Education, May 1999
  • Master of Business Administration, May, 2005
  • Doctor of Physical Therapy, May 2013
  • Texas PT license since 2002
  • Background primarily in home health
  • Auditor, adjunct faculty, presenter, regulatory

compliance officer

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Objectives

  • Implement effective strategies for identifying those at risk for

falls and reducing the risk

  • Evaluate geriatric age‐related changes that adversely affect

functional mobility

  • Assess the effectiveness of various interventions including

impairment‐based exercise and function‐based exercise at improving outcomes

  • Utilize effective documentation techniques to indicate skilled

care and reduce risk of denials

  • Discuss evidence‐based methods to improve adherence to

home exercise programs

  • Develop an effective multidisciplinary approach that addresses

a patient's functional needs

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Definitions

  • Evidence‐Based Medicine
  • Mosby’s Medical Dictionary, 9th edition
  • The practice of medicine in which the

physician finds, assesses, and implements methods of diagnosis and treatment on the basis of the best available current research, the physician's clinical expertise, and the needs and preferences of the patient.

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Definitions

  • 3 Pillars of Evidence‐Based Medicine
  • Clinician’s expertise
  • “Based off of my 20 years of clinical experience

treating hundreds of patients with your condition, I feel you would benefit from…”

  • Patient preferences and needs
  • “When my neighbor fell, she told me that she

received physical and occupational therapy, and both helped. I think I would benefit from both services too.”

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Definitions

  • 3 Pillars of Evidence‐Based Medicine
  • Best available current research
  • Level V opinions, case studies
  • Level IV non‐experimental studies
  • Level III non‐randomized studies
  • Level II randomized study
  • Level I systematic review
  • Which of the 3 pillars is

most important?

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The Ageing Adult

  • Sarcopenia
  • Decline of skeletal muscle tissue with age
  • Results in gradual loss of muscle tissue with age
  • Physically inactive people are at a higher risk
  • Can have a 3%‐5% loss in muscle mass every decade

after 30

  • Loss speeds up with age
  • Chronic illness causes faster degeneration
  • CVA, Parkinson’s, MD, CHF

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Definitions

  • The Geriatric “Athlete”
  • The International Classification of Functioning, Disability, and

Health (ICF model)

  • Health condion → Body structures and Funcons →

acvity limitaons → parcipaon restricons

  • Evolved from the Nagi model of Disability
  • Pathology → Impairment → Funconal Limitaons →

Disability

  • Examples

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The Ageing Adult

  • Cardiovascular changes
  • Slowed heart rate as a result of fatty deposits
  • Cardiac arrhythmias such A‐fib (risk factor for

CVA)

  • Heart valves become thicker
  • Can result in heart murmur
  • Thicker capillary walls
  • Slows exchange
  • Slower production of red blood cells

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The Ageing Adult

  • Age‐Related Diagnoses
  • Osteoarthritis
  • Degeneration of cartilage in the joint
  • Affects women 3 to 2 vs men
  • One of the leading causes of elective surgery in older

adults

  • Rheumatoid arthritis
  • Autoimmune disorder resulting in inflammation of the

joints

  • Increases in prevalence with age (peaks in 50s)

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The Ageing Adult

  • Age‐Related Diagnoses
  • Cerebrovascular accident (CVA)
  • Interruption of normal blood flow to the brain resulting in

focal lesions of neural tissue

  • Symptoms?
  • Transient ischemic attacks (TIA)
  • Commonly referred to as a mini stroke
  • Symptoms generally resolve quickly
  • Can be a warning for a CVA

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The Ageing Adult

  • Age‐Related Diagnoses
  • Parkinson’s disease
  • Affects dopamine production in the brain resulting in rigidity

and tremors

  • Congestive heart failure
  • Cardiac muscle strength has deteriorated, leaving heart

inefficient at pumping blood

  • Leading cause of hospitalization in people older than 65
  • Causes include arterial disease, myocardial infarction,

hypertension, and others 12

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The Ageing Adult

  • Age‐Related Diagnoses
  • Osteoporosis
  • Weakness of bones resulting from a decrease in bone

density

  • Increases the risk of fractures from a fall or loss of

balance

  • Question, do you fall and break you hip or break

your hip and fall?

  • NIDDM or Type 2 diabetes
  • The cascade

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The Ageing Adult

  • Age‐Related Diagnoses
  • What do all of the aforementioned diagnoses

have in common?

  • Fill in answer below:

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The Ageing Adult

  • Managing age‐related changes
  • Diet
  • Many adults over 50 are B‐12 deficient
  • Fatigue, malaise, weakness
  • Older adults become deficient in calcium and vitamin D
  • Leads to bone density loss
  • Potassium deficiency
  • Essential for bone health and muscle function
  • Symptoms include weakness, cramps, lethargia

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The Ageing Adult

  • Managing age‐related changes
  • Exercise
  • All of the previous age‐related diagnoses result in a

lack of mobility

  • Some (CVA and osteoporosis) may result from a lack of

mobility

  • Helps maintain functional mobility and independence

throughout lifespan

  • Helps to reduce risk for many chronic illnesses
  • Reduces fall risk in older adults

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Therapeutic Exercise Selection, Instruction, and Implementation

  • Defining functional limitations
  • Nagi model: Restrictions in the ability to actions,

tasks, and/or activities

  • ICF model: restriction in the execution of a task or

action by an individual

  • Deficits in: transfers, gait, dressing, bathing,

cooking

  • Other examples?

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Therapeutic Exercise Selection, Instruction, and Implementation

  • Defining impairments
  • A loss or abnormality at the tissue, organ, or

body system level, per the Nagi model

  • The ICF model’s corresponding section considers

problems in body structure or function such as significant deviation or loss

  • Deficits in: range of motion, strength, endurance
  • Other examples?

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Therapeutic Exercise Selection, Instruction, and Implementation

  • Impairments vs functional limitations
  • Which requires the complex training of a therapist to

identify?

  • Functional limitations are loss of a task
  • “My father has problems standing from his recliner”
  • A layperson can identify the lack of function
  • Impairments are the underlying reason why
  • “Your father is lacking range of motion in his knees and

strength in his hips”

  • Identifying why is the therapists’ domain

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Therapeutic Exercise Selection, Instruction, and Implementation

  • Impairment‐based exercises
  • Range of motion
  • Progressively taking the joint beyond its

available end range in order to achieve a new range

  • Assessment of range of motion
  • Can include stretching
  • Is the only goal of a range of motion exercise to

improve range of motion? What else can be gained?

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Therapeutic Exercise Selection, Instruction, and Implementation

  • Impairment‐based exercises
  • Strength
  • Defined as the amount of force a muscle can produce in a

single effort.

  • Assessment of strength
  • Walter Frontera, MD was the first researcher to use 80%
  • f a 1 repetition max as a basis for measuring strength

improvement (landmark 1988 study)

  • Guidelines for improving strength
  • What else improves when strength improves?

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Therapeutic Exercise Selection, Instruction, and Implementation

  • Impairment‐based exercises
  • Endurance
  • Muscular endurance
  • ability of a muscle to exert force against resistance while

avoiding fatigue

  • Can also be defined as musculoskeletal strength over

time

  • Assessment of muscular endurance
  • Cardiovascular endurance
  • The ability of the heart, lungs, and vascular system to

deliver blood and oxygen to the body’s tissues while working

  • Assessment of cardiovascular endurance

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Therapeutic Exercise Selection, Instruction, and Implementation

  • Exercise progression
  • Range of motion progression
  • It needs to move before it can be strong
  • Objective progression
  • Strength progression
  • It needs to be strong in order to sustain
  • Objective progression
  • Endurance progression
  • Muscular endurance vs cardiovascular endurance
  • Objective progression

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The Multidisciplinary Assessment of Functional Status

  • Assessment of functional status
  • A functional limitation is usually defined by the

amount of assistance a patient requires to complete a task

  • Ranges from totally independent to total assistance
  • And every thing in between
  • Modified independent, supervision assistance, minimal

assistance (up to 25%), moderate . assistance (26%‐ 50%), maximum assistance (51%‐75%)

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The Multidisciplinary Assessment of Functional Status

  • Defining functional limitations (revisited)
  • As defined by the Nagi model, restrictions in the

ability to actions, tasks, and/or activities

  • Obvious deficits that DO NOT require the complex

skills and training of a therapist to identify

  • Deficits in gross motor tasks such as transfers, gait,

dressing, cooking, and bathing

  • Frequently a reason that an older adult will seek
  • out therapy

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The Multidisciplinary Assessment of Functional Status

  • Assessment of functional status
  • Begins at evaluation
  • We assess
  • Gait via observational gait analysis and objective tests

such as Tinetti or dynamic gait index (DGI)

  • Transfers (supine to sit, sit to supine, sit to stand, stand

to sit, toilet, bathtub, bed to chair, car, etc.) via

  • bservation
  • Activities of daily living via observation and objective

tests such as the Barthel Index

  • Bed mobility (rolling, scooting, bridging) via
  • bservation

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The Multidisciplinary Assessment of Functional Status

  • Function‐based exercises
  • Designed to imitate movement patterns that
  • ccur in the functional activity
  • If the goal is to regain independence with a sit

to stand transfer, at some point we can use the transfer, or some component of it, as an exercise

  • Other examples?

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The Multidisciplinary Assessment of Functional Status

  • Progression of functional limitations
  • Impairment vs functional exercise
  • 2011 study saw both types of exercise improve

function

  • Impairment based sees gains in power
  • Functional training sees gains in postural control and

coordination

  • Limitations of the study
  • Healthy athletes

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The Multidisciplinary Assessment of Functional Status

  • Progression of functional limitations
  • Impairment vs functional exercise
  • 2015 RCT of 30 participants with knee OA
  • Ages 40‐65
  • Group A functional exercise training
  • Side stepping, braiding, multi‐directional walking,

dynamic balance training (more on this later)

  • Group B performed resisted exercise training
  • Hip abduction, hip adduction, LAQ, squats, SLR
  • Group C performed conventional exercises
  • Quad sets, hamstring stretches, SAQ

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The Multidisciplinary Assessment of Functional Status

  • Progression of functional limitations
  • Impairment vs functional exercise
  • Results of the study
  • Functional training group (group A) saw significant

improvement in pain (VAS), function (WOMAC), and functional task (LEFS)

  • Results of the groups B and C were mixed
  • Group B (resistance training) saw greater

improvement in functional task, Group C saw greater improvement with pain (VAS)

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The Multidisciplinary Assessment of Functional Status

  • Progression of functional limitations
  • Take away messages from the research
  • Exercise can be both impairment‐based and

function‐based

  • If pain is a concern, take caution with

resistance training

  • Possibility of overloading the joint and

exacerbating symptoms

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Multidisciplinary Approach to Reducing Risk for Falls

  • Balance training to reduce fall risk
  • 2010 study by Powers
  • Looked at the relationship between abnormal hip

mechanics and knee injury

  • Found that abnormal hip mechanics can lead a series of

problems in the knee joint

  • Abnormal hip movements include the tendency of hip

to collapse into adduction and internal rotation during closed chain hip flexion

  • What muscles are involved here?
  • What does this have to do with fall risk?

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Multidisciplinary Approach to Reducing Risk for Falls

  • Defining balance (impairment vs function)
  • Balance is a complex combination of sensory
  • rganization and motor coordination
  • Defined as the ability to keep the body’s center of

mass over the base of support

  • Combines visual, vestibular, and

somatosensory interaction

  • Also involves motor functions including

movement strategies and motor reactions

  • Can you walk with no proprioception?

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Multidisciplinary Approach to Reducing Risk for Falls

  • Defining balance (impairment vs function)
  • Sensory organization
  • Vision
  • Goal is to keep vision horizontal
  • Vestibular system
  • Involves semicircular canals for orientation navigation
  • Integrates utricle and saccule for horizontal and vertical

acceleration and deceleration

  • Somatosensory receptors
  • Includes joint position (proprioception and kinesthesia),

muscle tension (muscle spindles and golgi tendon organs), and skin (touch and pressure)

  • Integrates neuromuscular pathways by way of the medial

lemniscus and spinothalamic tract 34

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Multidisciplinary Approach to Reducing Risk for Falls

  • Evidence‐based balance assessment
  • Why assess balance?
  • 1/3 adults 65 and older will fall
  • For adults over age 80, incidence is 50%
  • Falling is a leading cause of injury‐related death in
  • lder adults
  • Balance and the older adult
  • Older adult will be at a higher fall risk
  • Age‐related changes, medical co‐morbidities, etc.

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Multidisciplinary Approach to Reducing Risk for Falls

  • Evidence‐based balance assessment
  • Good, fair, and poor are objective terms (from O’Sullivan)
  • Normal
  • Maintains balance with no support
  • Accepts challenge and can weight shift in all directions
  • Good
  • Maintains balance without support and minimal sway
  • Accepts moderate challenge; can pick objects off floor
  • Fair
  • Maintains balance with handheld support/minimal assist
  • Accepts minimal challenge; maintains balance while turning
  • Poor
  • Requires handheld support and mod‐max assist
  • Unable to accept challenge without loss of balance

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Multidisciplinary Approach to Reducing Risk for Falls

  • Evidence‐based balance assessment
  • Specialized balance testing
  • Single leg stance test
  • Berg balance scale
  • Timed up and go (TUG)
  • Tinetti
  • Falls Efficacy Scale (FES)
  • Dynamic gait index (DGI)

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Multidisciplinary Approach to Reducing Risk for Falls

  • Evidence‐based balance assessment
  • Selecting a test (or tests)
  • 2013 questionnaire
  • Found that therapists want to improve their balance

assessment, but:

  • Lack time
  • Lack knowledge
  • Lack resources
  • In other words, we stick with what we know
  • According to the study, clinical decision making is

based off of observation, not a test

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Multidisciplinary Approach to Reducing Risk for Falls

  • Patient‐based vs environmental fall risks (ICF model)
  • Personal factors
  • Internal traits that influence how a disability is

perceived

  • Gender, age, coping, past experiences, co‐morbidities,

education, etc.

  • Environmental factors
  • Make up physical, social, and attitudinal environment

in which people conduct their lives

  • Climate, terrain, architectural barriers

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Multidisciplinary Approach to Reducing Risk for Falls

  • Balance training to reduce fall risk
  • 2010 study by Powers (revisited)
  • Looked at the relationship between abnormal hip

mechanics and knee injury

  • Found that abnormal hip mechanics can lead a series of

problems in the knee joint

  • Abnormal hip movements include the tendency of hip

to collapse into adduction and internal rotation during closed chain hip flexion

  • What muscles are involved here?
  • What does this have to do with fall risk?

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Multidisciplinary Approach to Reducing Risk for Falls

  • Balance training to reduce fall risk
  • Common gait deficits related to OA
  • OA gait deficits and their affect on balance
  • What’s happening biomechanically?
  • What’s happening to proprioception?
  • What’s happening to muscle control?

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Multidisciplinary Approach to Reducing Risk for Falls

  • Balance training to reduce fall risk
  • 2014 systematic review
  • Reviewed 15 RCTs to assess the benefits of skilled

therapy to reduce falls in older adults with knee OA

  • Found that strength training, Tai Chi, and aerobics

exercise all reduced fall risk

  • Aquatic therapy and light exercise did not help
  • What do we strengthen?
  • What controls hip abduction? External rotation?
  • Why do we care?

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Practice lab

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Improving Adherence to Home Exercise Programs

  • Barriers to Adherence
  • Adherence to home exercise programs is poor following

discharge from physical therapy

  • Studies are revealing that barriers appear to be the

greatest predictor of adherence

  • Common barriers
  • Didn’t receive a program
  • One study revealed that 10% of patients did not

receive a program

  • No interest
  • Can we change this?

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Improving Adherence to Home Exercise Programs

  • Barriers to adherence
  • Poor health
  • Is there a correlation between exercise and overall

health?

  • Weather
  • Depression
  • Is there a link between exercise and depression?
  • Weakness
  • Does exercise affect strength

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Improving Adherence to Home Exercise Programs

  • Barriers to adherence
  • Fear of falling
  • Is there a link between lower extremity strength,

standing balance, and fall risk?

  • Shortness of breath
  • Does exercise improve cardiovascular endurance?
  • Low outcomes expectation
  • What was the design of the program?
  • How did the therapist prepare the patient?
  • Can we fix this?

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Improving Adherence to Home Exercise Programs

  • Facilitators to adherence
  • As previously stated, barriers rather than facilitators likely

predict adherence

  • Reviewing common barriers, what can we do?
  • Specific facilitators include
  • Better health status
  • Is this a correlation or causation?
  • Higher socioeconomic status
  • Supervised programs
  • Think wellness programs

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Improving Adherence to Home Exercise Programs

  • Facilitators to adherence
  • Social interaction
  • “I’m going to see my exercise family”
  • This is particularly powerful in older adults who live alone
  • Perceived benefits
  • If a patient believes the program has helped they are more likely

to continue with it

  • Instructor behaviors
  • Taking time to educate on the importance of the program, from

day one

  • Showing a caring attitude
  • Program design

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Improving Adherence to Home Exercise Programs

  • Designing a program
  • Program design has been shown to be a significant factor

in adherence in multiple studies

  • Program should be kept simple, but effective
  • Too few exercises and the program seems unimportant
  • Too many exercises becomes overwhelming
  • 2‐4 exercises has been shown to be optimal
  • A written program should be provided
  • And explained prior to discharge
  • Older adults need reminders
  • Encourage participating in group therapy if available

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Improving Adherence to Home Exercise Programs

  • Resources for long‐term adherence
  • The internet
  • Depending on tech knowledge and internet availability
  • Group classes
  • Local gyms
  • Assisted or independent living facilities
  • Local hospitals
  • Outpatient clinics
  • Long‐term wellness programs
  • Generally provide supervision and instruction
  • Scheduled follow‐up phone calls
  • Shows that you care
  • Shows importance of the program
  • Serves as a reminder to the patient

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Setting goals

Specific Measurable Achievable Relevant Time Bound Add in Function

  • Patient
  • Caregiver
  • ROM
  • MMT
  • Special test
  • TUG
  • Tinetti
  • Outcome

measures

  • Yes
  • No

Specific to:

  • patient
  • Caregiver

What do they want

  • Weeks
  • Visits

How do they relate back to a functional test

Ex:

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  • SMART goals

Goals also need to address underlying impairments (more on this later)

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Documenting Skilled Services

  • Setting goals
  • Goals must be patient specific and patient centered
  • Increase strength is not a goal
  • Goals must be tied to a functional outcome
  • Increase AROM to 0° ‐ 120° is not tied to any functional
  • utcome
  • Goals must be relevant to the patient
  • Setting a goal for stairs when patient has no stairs is

not relevant and not patient centered

  • Must have long and short term goals
  • CMS has been issuing denials due to no short term

goals

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Improper Goals What’s missing

Increase AROM to 0° ‐ 120°

  • What joint
  • What is the functional task
  • What’s the time frame

Increase strength

  • What muscle are we strengthening?
  • What muscle grade are we attempting to

achieve too

  • What’s the time frame

Improve balance

  • Any test that need to be approved?
  • What’s the function
  • Time Frame

Increase gait

  • What is the abnormal gait?
  • What are we trying to Improve on?
  • What’s the function for patient
  • Time Frame

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Documenting Skilled Services

  • Setting goals
  • In reviewing previous goals, how can we make them better?
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Documenting Skilled Services

  • The reason for referral/reason to get paid
  • Probably the single most important section
  • f the evaluation
  • Normally falls within the assessment
  • This is our justification to third party payers

as to why we are treating the patient

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Documenting Skilled Services

  • The reason for referral (Level 5 evidence from John

Adamson, PT, M. Div, GCS and Summit instructor)

  • Four components
  • Medical diagnosis and treatment diagnosis
  • How do they relate?
  • Summary of the functional deficits and underlying

impairments

  • Your problem list
  • A statement of medical necessity
  • Why now? What changed?
  • Comorbidities and complexities
  • Things that can affect progress

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Documenting Skilled Services

  • Documenting skilled intervention
  • Medicare requires ongoing documentation of patient

progress in order to justify continued care

  • Objective documentation of patient progress should be

regular and ongoing

  • It should reflect the care plan
  • Do we treat impairments or functional limitations?
  • Documenting goals as they are met shows specific

attention the patient’s overall plan of care

  • Progression with gait, transfers, and AROM are all good

areas to document progress

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Documenting Skilled Services

  • The assessment
  • On the evaluation
  • Explains why we are treating (see reason for referral)
  • Notes changes in function or condition
  • On daily notes
  • Explains progress, goals met, patient performance
  • Also gives an opportunity to explain lack of progress
  • On re‐evaluation
  • Why we need to continue?
  • On discharge summary
  • Why are we terminating therapy?

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Documenting Skilled Services

  • Explanation of homebound status
  • There must exist a normal inability to leave home
  • Leaving home must require a considerable and

taxing effort.

  • Absences from home for non‐medical purposes

must meet above and be of a short duration and infrequent in nature

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Documenting Skilled Services

  • Explanation of homebound status
  • What is a taxing effort?
  • Need supportive devices such as crutches, canes, wheelchairs,

and walkers

  • Special transportation
  • Assistance from someone else in order to leave their home

because of illness or injury

  • Condition that makes leaving the home medically inadvisable.
  • This must be documented every visit in narrative form
  • Check boxes are quick, but can lead to denials

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The End

  • Questions
  • Recommendations
  • Many thanks

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