Extension exercices in geraitric population (Full Version)

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supender -> Extension exercices in geraitric population (April 15, 2008 9:37:26 PM)

I recently switched job to a new outpatient clinic.Clinics owner who is PT Cert MDT  prescribes extension exercices ( regular prone on hands, repeated extension in standing)to geriatric populaion in  70's and 80's.I am really curious what physiological mechanisim would work to relieve their symptoms.
Upender Singh PT,MPTh,OCS
Board Certified  Clinical Specialist
Ortopaedic Physical Therapy




PTupdate.com -> RE: Extension exercices in geraitric population (April 15, 2008 9:47:29 PM)

While our spines need some degree of extension for daily tasks, including walking,  far too many patients have been injured from excessive extension tasks....often PPU, and done by certMDT's none the less!  In the past year, I have had 2 older persons that by the time they presented to me, were worse, now with myotomal strength deficits that were not reported by the therapist on the initial eval....  Odds are, they kept mashing their nerve root with stenotic narrowing, leading to the damage that I got stuck treating.



TexasOrtho -> RE: Extension exercices in geraitric population (April 15, 2008 9:58:34 PM)

I'm not crazy about it in older populations for the reasons John mentioned.  Not sure there's much of a "NP" to "H" if you get my drift.  Also the likelihood of posterior element disease is high in this population due to a dried out disc.  This would indicate these folks would tend to get flared up with extension.

That being said, some do indeed do well with it.  I may prescribe them in rare cases if more intuitive approaches fail, but I monitor them closely for signs of exacerbation or (god forbid) neurogenic signs while performing them.  I typically head right for the neuromuscular re-ed stabilization activities in this population.



james079 -> RE: Extension exercices in geraitric population (April 16, 2008 12:01:24 AM)

I felt quite faint when I read the term Geriatric. Only the science of caring for the older and frailer in Canada gets that tag. It must be the least appealing badge to give anyone. To reduce ageism in Canada we have those in the Golden Years, Senior Citizens and Mature Adults. Geriatric sounds like degeneration and decay. Thank you John and Rob for older persons and older population.
For mature citizens get out the weights and get on with your compound exercises and some fast walking.
Jim McGregor
As yet "Chronologically Gifted"!!



SJBird55 -> RE: Extension exercices in geraitric population (April 16, 2008 6:54:22 AM)

LOL James... by the time most folks get to be in their 80's, I think they call it like they see it.  They are geriatric and they know it. LOL  They say worse things about themselves and their age group and laugh about it.  I suppose we'll all see how we think when we reach our 70's and 80's.  I do believe you are correct though and "older" whatever is the term supposed to be used, even here in the US.  I can't keep up with all the "politically correct" jargon crap.  I honestly don't think changing the language reduces the concept of ageism - changing the language to sound more positive just makes us feel that we're creating a positive spin.  That's just me though.

I generally don't have that particular population go prone on hands.  Look at the person's wrists.  It just doesn't seem reasonable to put all that weight and pressure through the wrists with the wrist extended to the degree it would be extended.  The likelihood of the wrists tolerating the position over time just doesn't seem realistic to me.  Their hips also aren't as mobile into extension as they used to be.  And there is a greater likelihood that the spine is stenotic as John mentions.  In all honesty, I can't say I put that population in that position at all - the negatives outweigh the benefit.

supender, you are being quite vague.. what symptoms?  If there are radicular signs through posterior thigh region, sometimes sidelying over a pillow is helpful to get control of the symptoms.  If there are radicular signs through anterior thigh region, sometimes supine with involved lower extremity hanging down over edge of bed does wonders.  In that position, some patients need to hold the opposite extremity in a position of knee to chest with their hands because of low back complaints on that side that occur with stretching the opposite extremity into what appears to be some hip extension.  Some of the neurodynamic assessment tests work well as exercises to reduce the radicular symptoms too.

There is one exercise machine that most all actually like.  This population also responds well to it.  The back extension machine.  Generally the person is seated in it.  Because of the starting position, I do need to teach everyone to bend forward at their hips and to keep their spines "tall."  If you actually watch the person perform, they do not really move past upright or maybe just a tad into some lumbar extension.  Generally it doesn't cause increased pain or increase radicular symptoms.  (My rule to them is no increased pain and no peripheralization of symptoms.)  Believe it or not, the patients request it the next time they walk through your doors!  THAT amazes me.  I don't initially treat the activity as a strengthening activity though.  I'm assuming that something happens neuromuscularly.  The first session, I spend a lot of time talking, educating on positioning and then only have them do lighter resistance for 5-10 repetitions and that's the end of that session on it.  The return visit, if no increase in symptoms occurred, I then have an attempt at 3x10 at the light resistance.  The following visit, if no undesirable effects occurred... then they start with the resistance they had been doing for 30 reps, then the next plate for 30 reps and then the next plate for 30 reps.  I generally only have them perform 3 progressively increasing resistance plates for 30 reps each.  Patients are pretty good at communicating they do or don't want to have resistance increased from session to session (they'll help determine the starting plate).  I honestly don't know what occurs with that exercise, but there is no grumbling or complaining about it and the patients actually request it.



jlharris -> RE: Extension exercices in geraitric population (April 16, 2008 11:29:25 AM)

"Mature Adults"

Reminds in PT school how it drilled into us that it's a "residual limb" and not "stump".  Then I worked with those with amputations and this is how most of my interactions went:

ME: "how's your residual limb today"
THEM: "My what?"
ME: "your residual limb"
THEM: "Oh, you mean my stump?"
ME: "yeah, your stump"



Shill -> RE: Extension exercices in geraitric population (April 16, 2008 12:30:56 PM)

People who are older should not be excluded from doing extension just because they are older.  If their symptom behavior and their evaluation findings point one in the direction of extension for directional preference, then try extension.  Pay attention to what they get both during and after.  Its not necessarily important how much they extend, the intent is to relieve symptoms, not create gymnasts.  Only considering flexing just because they are old is no better than only considering extending "because the MRI said its a disc".  Base what you do on what you see and what the evaluation tells you, not a preconceived notion of what you should to based solely on age.



TexasOrtho -> RE: Extension exercices in geraitric population (April 16, 2008 12:54:06 PM)

quote:

ORIGINAL: jlharris

"Mature Adults"

Reminds in PT school how it drilled into us that it's a "residual limb" and not "stump".  Then I worked with those with amputations and this is how most of my interactions went:

ME: "how's your residual limb today"
THEM: "My what?"
ME: "your residual limb"
THEM: "Oh, you mean my stump?"
ME: "yeah, your stump"


My favorite was "tetraplegia" instead of "quadraplegia"...



supender -> RE: Extension exercices in geraitric population (April 16, 2008 1:24:32 PM)

I am sure seniors who have directional preference for extension would benefit from extension exercices( to some extent).But my quest is,if they are ever likely to centralise with extension exercise(considering the loss of  fluidity in their disc and developing stenosis).If ,yes what mechanisim would likely to cause it.

Upender Singh PT,MPTh,OCS
Board Certified  Clinical Specialist
Ortopaedic Physical Therapy



steve -> RE: Extension exercices in geraitric population (April 16, 2008 1:50:40 PM)

Suspender,

In response to your question "What mechanism would likely cause centralization" I think we need to get away from a structural paradigm as the mechanism by which these people get relief and think that likely it is a neurophysiological effect of movement that causes pain relief. Steven George did some interesting work in this area recently.

I would also suggest that just like the older patient does on occassion respond to extension based exercise and simple age should not be a reason for not using these exercises (Or any treatment ie. manipulation) IF they respond with centralization or abolishment of their pain. This stated, I usually find that their directional preference, if present, is flexion.

Steve



SJBird55 -> RE: Extension exercices in geraitric population (April 16, 2008 3:34:00 PM)

With flexion, care does need to be taken... osteoporosis can be a definite factor.  Research is not clear at this point because both kinds of studies can be found... but here in the states, it is being recommended that extension is preferred to flexion due to the forces that occur on the vertebral bodies during flexion.  Basically, bone health should be considered even when determining directional preference.



supender -> RE: Extension exercices in geraitric population (April 16, 2008 8:30:24 PM)

I agree with you steve that I need to think out of the structural paradigm.Neurophysiological mechanisim definitely can explain a lot of it.However,SJ bird I think Both knee to chest,Quadriped trunk flexion, saeted flexion tecnhniques are safe  flexion techniques even with mild to moderate amount of osteoprosis, since the intervertebral loads are not that high.
                 
Upender Singh PT,MPTh,OCS
Board Certified  Clinical Specialist
Ortopaedic Physical Therapy



rwillcott -> RE: Extension exercices in geraitric population (April 16, 2008 9:37:47 PM)

jharris,

How's you 'affected side' (instead of injured or bad)

My what?

Your affected side?

Oh you mean my sh*%$y side.



SJBird55 -> RE: Extension exercices in geraitric population (April 16, 2008 10:36:00 PM)

Upender, I was just planting the seed to remember osteoporosis.  Spinal flexion can be achieved in a variety of ways.  I wasn't going to assume what was being implied.

I must be the worst because I'm horrible at being politically correct with all the changing recommendations to not offend anyone.  Sometimes I wonder if we are doing a disservice by being politically correct and using positive language on the crap that does happen in people's lives. 



Kaden -> RE: Extension exercices in geraitric population (April 16, 2008 11:49:38 PM)

Upender,

I would agree with SJ that flexion in folk with osteoporosis needs to at least register as a concern on the radar.  I would agree with you that knee to chest and maybe 4 point flexion would be okay in this population but I would disagree that seated flexion loads are not significant.

Not to take this off on an osteoporosis tangent.  But, I think extension (at least prone lying or prone on elbows) can provide some decent benefits for these folks.  One by decompressing the anterior spinal structures and two hopefully promoting some extension for these chronically flexed folks.

Obviously with this group we have some foraminal narrowing issues and extension may not be tolerated by many but that is not to say one should completely avoid it as a rule.



rwillcott -> RE: Extension exercices in geraitric population (April 17, 2008 7:37:07 AM)

What does McKenzie recommend for these folks when it comes to extension?  I'm sure this must be covered in his text.  I'm thinking prone lying on forearms instead of a full press up.  Most wouldn't be able to achieve full extension in prone and would be limited by pain before getting to end range.



ptim -> RE: Extension exercices in geraitric population (April 17, 2008 9:21:28 AM)

I don't think there is any reference to age in the McKenzie text. A mechanical evaluation is performed regardless of the age, and their direction preference is dictated by the symptom response to movement.
Personally, I see more extension responsers than flexion repsonders in this group, not as many as in younger patients, but still more than flexion.
The problems I see is that people become afraid to move them in a particular direction, either avoid flexion because of osteoporosis or extension because thats 'bad' for these patients, or they move them once and it produces pain so they stop without fully establishing the response to the movement.
If you follow the progression of force and monitor the symptoms reponse, the McKenzie approach is very safe.



rwillcott -> RE: Extension exercices in geraitric population (April 17, 2008 2:09:29 PM)

ptim,

Your right.  The Mckenzie system has a built in safe guard if the progression of forces are performed properly.  The pain with extension with this population usually is due to a clinician jumping right into prone extensions without following the proper progression of forces. 



ptim -> RE: Extension exercices in geraitric population (April 17, 2008 2:23:23 PM)

rwillcott
Also moving them too far too fast and not giving a derangement time to reduce



supender -> RE: Extension exercices in geraitric population (April 17, 2008 3:14:51 PM)

I am not McKenzie certified,but I use TBC classification.And as we know specific exercices have been greatly borrowed from Mc Kenzie approach.In my obersvation,too close monitoring of symptom intensity and not location leads to missing of centralizers in both TBC ( they either get classified based on directional preference or other subgroups) and McKenzie( classified in to dysfunctional or postural syndrome).There is not enough evidence for effectiveness of using directional preference or classifications of postural syndrome and dysfunctional syndrome.In my experience classifying paitients based on directional preference,postural syndrome,dysfunction syndrome while they have centralisation movement pattern reduces the efficacy of  treatment approach.What does mckenzie system use to avoid that overlap.I think standardisation of the definition of centralisation,use of numeric overlay pain diagram is a good start.

Upender Singh PT,MPTh,OCS
Board Certified  Clinical Specialist
Ortopaedic Physical Therapy



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