Therapeutic exercise

Definition

Therapeutic exercise can be defined as a specific program of regular exercise with certain objectives. It refers to physical activity undertaken to treat chronic musculoskeletal, cardiopulmonary, or neurologic conditions as part of a rehabilitation program, as distinct from exercise undertaken for general health maintenance, recreation, or as a social activity. Therapeutic exercise may vary from exercises directed toward a specific body part or muscle group to general workouts intended to restore a patient recovering from illness or surgery to better physical condition.

Description

There are four basic types of therapeutic exercises, aimed at improving the senior's strength (resistance training), flexibility, endurance, and stability or balance. When possible, the doctor or physical therapist incorporates activities that the senior enjoys as well as those intended to bring about a specific result; for example, a senior with arthritis who enjoys swimming may be given therapeutic exercises intended to increase range of motion that can be performed in a swimming pool. Therapeutic exercise is always tailored to the fitness needs of the individual senior. Seniors with certain heart conditions or blood pressure that drops while exercising should be supervised by a doctor during their exercise period.

Some types of therapeutic exercise can be modified for seniors; for example, weight training to increase muscle strength can be carried out while sitting if the senior has difficulty standing or walking. Patients with osteoarthritis may prefer three 10-minute exercise sessions spaced out over the day to one 30-minute session; they will still gain health benefits as long as the shorter sessions add up to 30 minutes per day.

Strength training

Strength training is done to build up muscle tissue; it typically consists of graded exercises involving resistance training. This type of therapeutic exercise is important for seniors because most persons lose between 20 and 40 percent of their muscle tissue as they age. Strength training may be high or moderate in intensity.

Most forms of high-intensity strength training involve free weights that the patient swings or moves through a distance or machines that use either weights or air pressure that the patient must push against. The muscles are trained by repetitions of the pushing or lifting motion. For healthy elderly patients, a fitness machine can be set to 60 to 80 percent of the one-repetition maximum, which is the weight that the person can lift once. Elderly patients who are in good condition can perform two sets of 10 repetitions each on several different machines during a strength training workout. When done twice a week, strength

training can improve a senior's strength by 30 to 150 percent during the first year of exercise.

Moderate-intensity strength training increases a senior's strength by 10 to 20 percent over a period of several months and helps to maintain it. This type of strength training uses calisthenics, which are exercises that employ the body's own weight for resistance; cuff weights, which can be attached to ankles or wrists; or weighted elastic tubing. Calisthenics include such well-known exercises as sit-ups, push-ups, squats, and pullups. These moderate-intensity exercises are well suited for weak elderly patients and other seniors because they do not require expensive equipment or a trip to a gym or fitness center; they can easily be done at home.

Flexibility training

Flexibility training is generally low-intensity in terms of the strength or level of aerobic fitness required. Many seniors enjoy flexibility exercises, however, on the grounds that they confer a feeling of overall well-being. Most flexibility exercises consist of stretches, in which seniors slowly move their body into the desired position and hold it for 10 to 30 seconds. Flexibility exercises should be carried out after strength or endurance exercises, when the muscles are already warmed up. Seniors should not bounce or jerk into position but move gently and gradually. Flexibility exercises include such exercises as hamstring stretches, hip and shoulder rotations, calf and ankle stretches, and stretches of the triceps muscle in the upper arm.

T'ai chi and yoga are frequently recommended as a form of flexibility training for seniors. Many enjoy these forms of exercise because they can be done with a group of friends or as part of a class.

Endurance training

Endurance exercises provide the best-documented benefits of therapeutic exercise for the elderly. Walking is the most common form of endurance exercise practiced by seniors—about 50 percent of elderly people walk for exercise—and it is the one most frequently recommended by doctors. Walking can be easily incorporated into the senior's daily schedule of errands by going on foot to the post office, store, church, for example, rather than driving. One study showed that seniors who walk at least 2 miles a day on average lower their mortality risk by 50 percent. Other good forms of endurance training are swimming, cycling, dancing, walking up stairs instead of taking the elevator, golf (walking), gardening or heavy yard work, and low-impact aerobics. Jogging is not a good exercise for seniors unless they are already used to it.

The doctor may use a method called the target heart rate to calculate the intensity of endurance exercises that will provide the most health benefits for the senior. The target heart rate for moderate-intensity endurance exercise is 60 to 79 percent of maximal heart rate (measured in beats per minute). Maximal heart rate, which is usually determined by an exercise stress test , can also be calculated by subtracting the senior's age from 220. Thus seniors who have 70 years old would have a maximal heart rate of 150, and their target heart rate would be about 90–120 beats per minute during moderate-intensity endurance exercises.

Seniors whose endurance exercise programs are interrupted by a few weeks of illness or inactivity should return to exercising at a lower level of intensity. Strict bed rest leads to loss of muscle mass as well as to loss of muscular strength and aerobic fitness.

Stability or balance

Balance exercises are important for seniors because they lower the risk of falls—a major cause of disability in the elderly. Balance exercises include plantar flexion, in which the senior stands with hands on a table for balance and slowly stands on tiptoe, holding the position for 1 second and repeating the motion 8 to 15 times. After seniors feel steady while performing the exercise, they can gradually work up to holding the table only with a fingertip, then with no hands, then with eyes closed. Other balance exercises include side leg raises and hip or knee flexion. One exercise for balance that can be done while taking a daily walk is to walk heel to toe for short distances. Another is to stand on one foot for a few seconds while waiting in line or waiting for a bus, and alternate the feet every few seconds.

Demographics

According to the Merck Manual of Geriatrics, “Physical inactivity is the second leading cause (after tobacco use) of premature death” in the United States. Therapeutic exercise is often prescribed after an injury or diagnosis of a chronic disease or disorder because many elderly people do not get enough physical exercise. Only 20 to 25 percent of elderly persons exercise for more than 30 minutes 5 times or more per week. Women generally exercise less than men; however, low income and low educational level are more influential factors in lack of exercise than gender or advancing age.

Purpose

Therapeutic exercise in seniors serves a number of different purposes:

• Reducing mortality, even in obese persons and smokers. A number of studies have reported that seniors who exercise regularly have mortality rates 20 to 50 percent lower than their sedentary peers.
• Improved general sense of well-being and opportunities for social interaction.
• Improved sleep quality, which is significant because insomnia is a common problem in seniors.
• Preserving muscle strength, bone density, and lung capacity—factors that maintain mobility and hence independence.
• Creating a balanced energy state and reducing the risk of obesity. Excess weight is hard on aging joints and increases the risk of heart disease and type 2 diabetes.
• Maintaining or improving the flexibility and range of motion of joints, which contributes to the senior's functional ability.
• Lowering blood pressure.
• Lowering the risk of such psychiatric disorders as depression.
• Lowering the risk of falls and fall-related injuries, particularly when balance training is part of the exercise regimen.

Challenges

Seniors should be checked for potential health problems before beginning a regimen of therapeutic exercise. Some doctors use a questionnaire called the Physical Activity Readiness Questionnaire, or PAR-Q, as a preliminary to planning a program of therapeutic exercise. The PAR-Q has seven items asking for yes/no answers to such questions as chest pains, a history of high blood pressure, dizziness , and the like.

Seniors with any of the following medical conditions should be treated for them and have their condition stabilized before beginning a therapeutic exercise program:

• Unstable angina (chest pain caused by inadequate blood supply to the heart muscle)
• Uncontrolled irregular heart rhythm.
• Cardiomyopathy (disease of the heart muscle; may be genetic or caused by inflammation of the walls of the heart)
• Known or suspected dissecting aneurysm (abnormal blood-filled bulge in the wall of a weakened artery that is spreading along the length of the artery)
• Recent systemic or pulmonary embolus (air bubble or other abnormal particle circulating in the blood)
• Resting systolic blood pressure over 200 mm Hg or resting diastolic blood pressure over 110 mm Hg.
• Severe pulmonary hypertension (high blood pressure in the pulmonary artery).
• Thrombophlebitis (inflammation of the veins caused by blood clot formation).

KEY TERMS

Aerobic fitness —A measure of the amount of oxygen delivered to muscle tissue to keep it working. Any type of exercise that raises the heart rate and keeps it up for a period of time improves aerobic fitness.

Angina —A severe constricting pain or sense of pressure in the chest caused by an inadequate supply of blood to the heart tissue.

Calisthenics —A type of exercise consisting of simple movements intended to improve body strength and flexibility by using the body's own weight as resistance. The English word comes from two Greek words meaning “beautiful” and “strength.”

Deconditioning —Loss of physical fitness due to illness or inactivity.

Diastolic blood pressure —The lowest level of blood pressure in the arteries, which occurs at the point in the heart's cycle when its chambers fill with blood.

Pulmonary artery —The large artery that carries blood from the heart to the lungs to receive oxygen. It is the only artery in the body that carries deoxygenated blood.

Sedentary —Not physically active.

Systolic blood pressure —The highest level of blood pressure in the arteries, which occurs at the point in the heart's cycle when the heart contracts and pushes blood out through the aorta and the pulmonary artery.

Seniors with osteoporosis should follow very gradual increases in intensity and duration during strength and endurance exercises. While therapeutic exercise has been shown to increase bone density, this is best achieved in seniors with osteoporosis by increasing the number of repetitions for each exercise before increasing the weights used in strength training.

Although seniors are not always given physical fitness tests before starting a program of therapeutic exercise, some doctors and physical therapists use them as a way of evaluating the senior's level of aerobic fitness, or the amount of oxygen delivered to muscle tissue. The most common fitness test given to seniors is a 6-minute walk test. Periodic fitness tests may be given after the senior has started the exercise program as feedback to encourage the senior to continue with the program.

Risks

The most common health Risks of therapeutic exercise for seniors are muscle injuries and torn ligaments. Falls are also a risk, although the many health benefits of therapeutic exercise are considered to outweigh the risk of falls. There is also a temporary increase in the risk of sudden death during exercise if the senior has begun to exercise too vigorously after months or years of being in poor condition.

Results

Participating in an individualized program of therapeutic exercise approved by a doctor is one of the best strategies seniors can follow to maintain overall health and independence , speed recovery following surgery or illness, manage a chronic health condition such as osteoarthritis or osteoporosis, participate in social activities, and lower mortality risk. Seniors who are deconditioned, whether by long years of a sedentary lifestyle or by recent injury or illness, can still improve their fitness by modest amounts of low-intensity exercise. The NIA points out that even seniors who have already suffered disabilities or been diagnosed with diseases can benefit from regular long-term exercise; even 2–3 minutes of activity alternating with 2–3 minutes of rest over a 15-minute period is a worthwhile beginning. The most important aspect of therapeutic exercise is keeping up the program, as muscle strength and endurance decline rapidly after only a few weeks of inactivity.

Resources

BOOKS

Beers, Mark H., and Thomas V. Jones. Merck Manual of Geriatrics, 3rd ed., Chapter 31, “Exercise.” Whitehouse Station, NJ: Merck, 2005.

Hall, Carrie M., and Lori Thein Brody. Therapeutic Exercise: Moving toward Function, 2nd ed. Philadelphia: Lippincott Williams and Wilkins, 2005.

Kisner, Carolyn, and Lynn Allen Colby. Therapeutic Exercise: Foundations and Techniques, 5th ed. Philadelphia: F. A. Davis, 2007.

PERIODICALS

Fleg, J. L. “Exercise Therapy for Elderly Heart Failure Patients.” Heart Failure Clinics 3 (October 2007): 529–537.

Herman, T., et al. “Six Weeks of Intensive Treadmill Training Improves Gait and Quality of Life in Patients with Parkinson's Disease: A Pilot Study.” Archives of Physical Medicine and Rehabilitation 88 (September 2007): 1154–1158.

Netz, Y., S. Axelrad, and E. Argov. “Group Physical Activity for Demented Older Adults: Feasibility and Effectiveness.” Clinical Rehabilitation 21 (November 2007): 977–986.

Rooks, D. S., S. Gautam, M. Romeling, et al. “Group Exercise, Education, and Combination Self-Management in Women with Fibromyalgia: A Randomized Trial.” Archives of Internal Medicine 167 (November 12, 2007): 2192–2200.

Sullivan, K. J., D. A. Brown, T. Klassen, et al. “Effects of Task-Specific Locomotor and Strength Training in Adults Who Were Ambulatory after Stroke: Results of the STEPS Randomized Clinical Trial.” Physical Therapy 87 (December 2007): 1580–1602.

Vizza, J., et al. “Improvement in Psychosocial Functioning during an Intensive Cardiovascular Lifestyle Modification Program.” Journal of Cardiopulmonary Rehabilitation and Prevention 27 (November/December 2007): 376–383.

OTHER

“Exercise: A Guide from the National Institute on Aging.” National Institute on Aging (NIA). NIH Publication No. 01-4258. Bethesda, MD: NIA. 2007. [cited March 21, 2008]. http://www.nia.nih.gov/NR/rdonlyres/8E3B798C-237E-469B-A508-94CA4E537D4C/0/Exercise_Guide907.pdf.

Lieberman, Jesse A. “Therapeutic Exercise.” eMedicine. June 26, 2007 [cited March 21, 2008]. http://www.emedicine.com/pmr/topic199.htm.

“Physical Activity Readiness Questionnaire (PAR-Q).” July 17, 2006 [cited March 21, 2008]. http://www.d.umn.edu/kmc/student/loon/soc/phys/par-q.html.

ORGANIZATIONS

American Association of Retired Persons (AARP) Fitness Guide to Walking, 601 E St. NW, Washington, DC, 20049, (800) OUR-AARP (687-2277), http://www.aarp.org/health/fitness/walking/.

American Physical Therapy Association (APTA), 1111 North Fairfax St., Alexandria, VA, 22314, (703) 684-APTA (2782), (800) 999-2782, (703) 684-7343, http://www.apta.org/.

National Heart, Lung, and Blood Institute (NHLBI), PO Box 30105, Bethesda, MD, 20824, (301) 592-8573, (240) 629-3246, nhlbiinfo@nhlbi.nih.gov, http://www.nhlbi.nih.gov/index.htm.

Rebecca J. Frey Ph.D.