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Exercise

Creating an exercise program for your geriatric patients

John W. Downes, D.C.

Exercise, the process of overloading muscle, bone, heart and lungs to increase capacity or endurance, is usually thought of as recreation. But what we do and how we function day in and day out is the key to maintaining the optimum abilities the body has to offer. If you view life as an athletic event with no timeouts, then staying fit through exercise just makes good sense. The “Baby Boomers,”ages 35-54, are busy becoming sedentary or fighting against the forces of time which cause aging, but the largest increase in sports-related injuries belongs to the 65 and older group—more than a 54 percent increase in these injuries was reported from 1990 to 19961.

We all agree that inactivity seems to increase with aging. Although about one half of the overall population reports doing some routine exercise activities, only 30 percent of those age 65 and older report any regular exercise2. So where does one begin with the process of exercise and how does one progress?

The four primary areas of exercise involve balance, stretching, strength and endurance. But underlying all of these areas is the concept of “core stabilization.” Researcher Andry Vleeming reveals in his book, Movement, Stability and Low Back Pain, that certain core muscles work together to protect the spine and spinal cord from excessive internal and external forces3. The transversus abdominis, multifidus, diaphragm and pelvic floor work together to turn the trunk into a cylinder of strength that guards the spine. This is critical as a foundation for the spine, lower extremity and upper extremity function. Assessing your patient for core control is easy and the benefits are well documented. Once core exercises are initiated, if needed, the next great challenge is balance.

Balance is the single most important factor underlying movement strategies. It is the position from which we start all activities, so assessment of balance is the next step in the process. Bohannon (et.al.) found that timed balance decreased with aging.4 A simple test is this: Use 30 seconds as the base and have your patient stand on one foot, hands on hips and with their eyes open. After three attempts on each foot, average the time for each side, then repeat the assessment with while the patient has their the eyes closed. The time stops if the patient moves their hands off their hips, jumps, hops, or puts the foot down. (Table 1) The ability to succeed in this test directly relates to maintaining the center of gravity, i.e. balance.


TABLE 1

The three strategies you may see during this test is ankle, hip or stepping. The ankle strategy is the most efficient, and is reflected by a level pelvis and increased activity at the foot and ankle during single leg standing. Hip strategy is less efficient, and the patient will tend to lift the pelvis as if to balance it over the hip. As the hip strategy is employed over time the gait will grow wider and shorter, reflecting the deteriorating ability to balance. Finally, the stepping strategy is utilized when balance cannot be maintained and the limit of stability is passed. It is interesting to note that balance is maintained through the somatosensory, visual and vestibular systems, but with aging the body tends to depend on more on vision and less one these systems. It is possible to ‘exercise’ this sensorimotor system by challenging the body to maintain balance for longer periods of time. The geriatric patient may have to start by using support with eyes open only until a sense of control is established, but great strides can be made with as little as a minute a day per leg5.

Stretching, strengthening and endurance must be guided by the base condition of the patient. A simple method to follow is the principle of all reconditioning programs, “Overload and Progression.” It is the condition of overload that causes the body to respond, but too much too soon will only produce pain, swelling and decreases in flexibility rather than improvements. So where do you begin with a geriatric patient? If you are not familiar with fitness assessment and you want a safe place to start, I recommend the progression developed by the President’s Council on Physical Fitness and Sports. They are arranged in three levels of difficulty. Once the patient has completed all of the exercises in Level 1, proceed to the next level.

Level 1
(The balance and assessment stage, as outlined previously)

Level 2
Shoulder shrug: For the upper back, to tone shoulders and relax the muscles at the base of the neck. Life shoulders way up, then relax the. Suggested repetitions: 8-10.

Sitting Single Leg Raises: Strengthens hip flexor muscles and tone lower abdominal wall. Sit erect, hands on side of chair seat for balance, legs extended at angle to floor. Raise left leg waist high. Return to starting position, then right. Suggested repetitions: 10-15 each leg.

Knee Lift: Strengthens hip flexors and lower abdomen. Stand erect. Raise left knee to chest or as far upward as possible. Return to starting position, then right. Suggested repetitions: five each leg.
Leg Extensions: Tones upper leg muscles. Sit upright. Lift left leg off the floor and extend it fully. Lower it very slowly, then right. Suggested repetitions: 10-15 each leg.

Back Leg Swing: Firms buttocks and strengthens the lower back. Stand erect behind chair, feet together, hands on chair back for support. Lift one leg back and up as far as possible keeping the knee straight. Return to starting position, then other leg. Suggested repetitions: 10 each leg.

Quarter Squat: Tones and strengthens lower leg muscles. Stand erect behind a chair, hands on chair for balance. Bend knees, then rise to an upright position. Suggested repetitions: 8-12.

Arm Curl: Strengthens arm muscles. Use a weighted object not more than five pounds. Stand or sit erect with arms at sides, holding weighted object. Bend your arm, raising the weight. Lower it, then the other arm. Suggested repetitions: 10-15 each arm.

Modified Knee Push-Up: Strengthens upper back, chest, and back of arms. Start on bent knees, hands on floor under and slightly forward of shoulders. Lower body until chin touches the floor. Return to starting position. Suggested repetitions: 5-10.

Side Lying Leg Lift: Strengthens and tones outside of thigh and hip muscles. Lie on right side, legs extended. Raise left leg as high as possible. Lower to starting position. Suggested repetitions: 10 each side.
Alternate Leg Lunges: To strengthen upper thighs and inside of leg. Also stretches back of leg. Take a comfortable stance with hands on hips. Step forward 18” to 24” with right leg, while extending arms straight ahead. Keep left heel on floor. Shove off right leg and resume standing position. Suggested repetitions: 5-10 each leg.

Level 3
Seated Alternate Dumbbell Curls: Strengthens biceps of upper arms. Sit comfortably on a flat bench with arms at sides. Hold a pair of dumbbells with an underhand grip, so that palms face up. Bending left elbow, raise dumbbell until left arm is fully flexed. Lower left dumbbell while raising right dumbbell for the elbow until right arm is fully flexed. Breathe normally. Suggested repetitions: 1-2 sets of 6-10 repetitions each arm.

Alternate Dumbbell Shrug: Strengthens muscles in shoulders, upper back and neck. Stand comfortably with dumbbells in each hand. Elevate shoulders as high as possible, rolling them first backward and then down to the starting position. On the second repetition, roll the shoulders forward and down. Alternate first backward and then forward. Exhale as you lower the shoulders. Suggested repetitions: Five forward, five backward.

Dumbbell Calf Raise: Strengthens calf muscle and improves range of motion of ankle joint. Stand with feet shoulder-width apart, weights in each hand. Raise up on toes lifting heels as high as possible. Slowly lower heels to starting position. Breathe normally. Suggested repetitions: Five with heels straight back, five with heels turned out, five with heels turned in.

Dumbbell Half Squats: Strengthens thigh muscles in front. Stand with feet shoulder-width apart and heels on a 2”x4” block (not necessary, but preferred). Holding weights in each hand, slowly descend to a comfortable position where the tops of the thighs are about at a 45-degree angle to the floor. Inhale on the way down. Ascend to the upright position with knees slightly bent. Exhale on the way up. Suggested repetitions: 10-12.

These exercises are a safe starting point but several may be modified due to patient response. “Too much, too soon” may result in discomfort, slight swelling and decreased range of motion. If this occurs, reduce intensity and frequency of exercises to allow recovery.

The final concept is that of maintaining cardiorespiratory endurance. The best pathway is walking for those who can, or swimming or riding a stationary bike for those who can’t or shouldn’t walk. When walking, choose a comfortable time of day, not too soon after eating or in extreme temperatures. Start walking a quarter of a mile each day the first two weeks; half a mile each day the third week; three quarters of a mile the fourth week; and one mile the fifth week. Continue this walking regimen five days a week with a target of one mile each day the sixth week. Watch for the signs of overexertion: panting, nausea, sleep disturbance or if your breathing does not return to normal within 10 minutes after exercising.6 Likewise, monitor the target heart rate for your patient during times of exercise. An easy rule of thumb for moderate exercise is that the target heart rate can be computed by subtracting the patients age from 220, then multiplying that figure by 70 percent (.70). For example, a 65-year-old would try to maintain a pulse of 108.
In conclusion, designing an exercise routine for your geriatric patients must be an aggressive effort to safeguard their health. Take a word of advice from one of my colleagues: “Attack success!” Find what your patient can do and build upon that foundation, and you will encourage them to make exercise a life changing event.

References
1. Rutherford GW, Schroeder TJ. Sports-related injuries to persons 65 years of age and older. U.S. Consumer Product Safety Commission, WDC, 4,1998.
2. Physical activity and health: a report of the Surgeon General. Atlanta: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion. Pittsburg: President’s Council on Physical Fitness and Sports, 1996.
3. Vleeming A, Movement, Stability and Low Back Pain, Churchill Livingstone: London, England, 1997.
4. Bohannon RW, Larkin PA, Cook AC, et.al. Decrease in timed balance test scores with aging. Physical Therapy, 647, July 1984, 1067-1070.
5. Janda V, Va’vrova’M 1990. Sensory Motor Stimulation: A video. Presented by JE Bullock-Saxton. Brisbance, Australia, Body Control Systems. “Pep Up Your Life, A Fitness Book for Seniors”, President’s Council on Physical Fitness and Sports. 1991 AARP.

John Downes, DC, is a faculty member of the Master’s Program in Sport Health Science at Life University and is in private practice at Performance for Life. Questions or comments may be sent to jdownes@life.edu.

© Copyright 2002 Today's Chiropractic

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