|Susie Goodridge, PT, CSCS, and client Jennifer Conforti.|
The role of rehab in the 21st century is changing, spurred in part by rising health care costs and by an aging Baby Boomer population. Some therapists have begun focusing primarily on prevention—aiming to help clients change their habits to avoid injuries. Physical therapists who focus on the healthy demographic aim to keep them healthy long-term—which could result in decreased health care costs and an overall improved quality of life. As of April 1, 2009, the pool of US Baby Boomers—whose ages span 45 to 63—numbers some 76.6 million, according to Robert Bernstein, a spokesman for the US Census Bureau. A wide-ranging government-based initiative called Healthy People 2010 (www.healthypeople.gov) actively seeks to enhance and expand Americans’ quality of life. The rehab profession’s move toward wellness and preventive therapy complements the initiative and suggests a new path for PTs that will be increasingly important as America ages.
YES GAIN/NO PAIN
Therapists help adult clients prevent injuries by assessing their 3-D environments and by offering ergonomic solutions to problems traced back to office work or home life. Everyday tasks such as sitting at the computer, talking on the phone, or sleeping, which engage particular postures, can be at the root of client problems. Assessment includes testing of muscle strength, range of motion, and flexibility. “We want to look for any imbalances that exist within the person and then educate them on how to strengthen the imbalances,” says Susie Goodridge, PT, CSCS, Westwood Physical Therapy, Los Angeles. She examines modalities and manual skills, and encourages client follow-through with home programs to perpetuate advances and foster further improvement. The facility offers wellness programs that extend beyond clinical visits into the clients’ lives, and this progressive extension of care will create a new facet in the continuum of care provided by PTs.
Evidence-based research paves the way for effective treatment strategies and programs. The facility engages in cutting-edge treatments and monitoring programs with patient records that document functional outcome measures and quantify client improvement. “If we want to use ultrasound on a frozen shoulder or laser on an osteoarthritic knee, there’s research that supports that treatment,” Goodridge says. She notes that new research often stems from modalities—lasers have attracted a buzz. Research is showing that lasers help soft-tissue wounds heal quickly by increasing cellular activity. Goodridge embraces modalities, but emphasizes exercise-based and manual therapy. She says a recent trend is integrating Pilates and yoga into physical therapy and rehab. She treats mainly orthopedic clients, whose impairments can run the head-to-toe gamut from jaw pain (TMJ) to foot pain, usually stemming from muscle, joint, and spinal problems.
Maria Martos, MS, certified neuromuscular therapist and owner of Sagewood Wellness Center, Dana Point, Calif, says in terms of injury prevention, the No. 1 belief that gets people in trouble is no pain/no gain—which may be reinforced by uninformed trainers. “I tell people, ‘Get rid of that mentality. Don’t power through the pain, because your body is very intelligent, and if your body is telling you that it’s in pain, it’s because something’s wrong,’ ” says Martos, who specializes in treating minor, severe, and chronic pain, and injury rehabilitation and prevention. She has a certification in sports massage. Martos urges clients who feel pain during exercise to back off for a while and, after injury, to allow sufficient time for rest and recovery to avoid compounding the injury. She recommends stretching before and after sports or a workout for injury prevention, walking for 3 to 5 minutes before exercise to get the blood circulating, and stretching muscles that will be used. “You want to bring the blood into the tissues, you want to flush out the old blood, you want to get a little flexibility so your muscles are ready for that performance,” she says. “After your workout, you really want to make sure that you stretch to return that muscle to a normal resting length” to prevent muscles from becoming shortened and less functional, and to remain balanced.
FIT FOR LIFE
Members of the American Senior Fitness Association (SFA), New Smyrna Beach, Fla, are primarily fitness instructors and personal trainers of older adults, whose role involves prevention and wellness care. Some work in rehab settings, but many serve in physical activity promotion capacities in health clubs, senior centers, YMCAs, parks and recreation departments, assisted living facilities, and nursing homes, says Janie Clark, MA, president of SFA.
SFA-trained fitness instructors and trainers complete professional education programs, which recently won the National Council on Aging, Health Promotion Institute, 2009 Best Practice Award. “The programs teach them how to implement individualized exercise training plans, taking into account the participant’s health history, lifestyle habits, risk factors, functional fitness level, and motivational prompts,” Clark says.
SFA professionals get medical clearance for older clients who participate in physical activity, ask the client’s personal physician to set training limits if necessary, and obtain a list of clients’ medications—following SFA guidelines for adjusting workouts to accommodate the medication regimen, Clark says. They also conduct an evidence-based functional fitness assessment. “It might, for instance, point to the need for balance and fall-prevention exercises; it might indicate an emphasis on muscle strengthening and/or stretching activity; it could point to a need for greater aerobic endurance and improved energy levels for successful engagement in activities of daily living; in some cases, it may suggest the prudence of starting out with chair-seated work or swimming pool exercise for safety and prevention reasons,” she says. “The ideal program for one client might involve regular walks outdoors, supplemented by energetic gardening, while another client might thrive in the gym using exercise equipment, and yet another might respond best given the social benefits of a group-exercise class,” Clark says.
To help prevent back injuries, trainers follow best-exercise practices, such as warming up the spine in a vertical position before performing lateral movement involving the neck or back, never having older adult clients bend downward while turning or twisting the spine at the same time, and ensuring that clients provide manual support for the back when bending the trunk in any direction and while in any position, Clark says.
Walking-wounded, weekend-warrior Boomers present with an array of injuries, especially in sunny climes, where they partake in outdoor activities year-round: tennis elbow (lateral epicondylitis), golfer’s elbow (medial epicondylitis), rotator cuff injuries, pulled hamstrings, knee pain such as patellofemoral syndrome, Achilles tendonitis, and plantar fasciitis.
As people age and their muscles lose elasticity, they are not as flexible nor do they rebound as fast from exercise or injury. Sedentary weekdays can morph into exercise marathons come the weekend. “A 20-year-old can go out and run 5 miles and they might be a little sore, but they’ll be better within a couple of days,” Goodridge says. “Someone who’s in their 50s, if they haven’t been keeping up with [their exercise] and they try to run 5 miles or go for a 25-mile bike ride, could easily pull something.” Many have soft-tissue injuries resulting from pulling muscles. Most injuries average 6 to 8 weeks to rehab, Goodridge says. Core stabilization and strengthening of trunk muscles provide a strong foundation for all activities. In addition, she recommends stretching after exercise to further reduce the risk of injury.
DAYTIME COUCH POTATOES MINUS THE TV
Boomers may have active minds but static bodies, parked in front of a computer screen on workdays. “We live in a society where you don’t even have to move any more,” Goodridge says. “You can do everything through e-mail so you don’t have to walk to your colleague’s office down the hall to tell them something.” Poor posture may lead to low back pain, and may predispose some to injuries of the lower back. Chairs with built-in ergonomic controls can be beneficial, but many do not use them properly. Goodridge emphasizes that computer setup is important: the keyboard should be positioned ergonomically so people avoid holding their arms up. Otherwise, the upper trapezius and neck muscles may suffer from overuse, triggering pain. She regularly advises people on how to sit, stand, lift, and sleep properly, and makes them aware of the benefits of lumbar support for the low back.
THE WELLNESS AND PREVENTION TOOLKIT
Gauravi Merchant, PT, MPA, executive director, Physicians Choice Physical Therapy, West Los Angeles, says PTs can often help people prevent fall-related injuries by helping them to improve their balance and offering tips for fall recovery and prevention. ‘’Teaching people the right body mechanics, stretching and strengthening the weak muscles—and by that, preventing sports-related injuries from overuse and poor body mechanics when playing sports,” she says.
Her tips for clients:
For injury prevention: good posture, good body mechanics, improving core strength, and regular exercise.
For low back pain prevention and recovery: good posture and body mechanics at all times; core strengthening, “We use Pilates-based physical therapy to reeducate muscles and improve core strength; and regular aerobic exercises such as swimming and cycling.”
For recovery: ice first with all acute back injuries; pain management to decrease muscle spasm using modalities and soft tissue and joint mobilization; in subacute phase, gradual strengthening program for core and lower extremities; education about what to do/not do in terms of body mechanics and posture; home exercise program to recover and prevent future back injuries.
Neck pain too is often linked to poor posture. Boomers may spend long stretches commuting via car, with arms out in front, slouching forward, chin jutting forward—harking back to the poor daytime pose. Proper driving posture is key to avoiding long-term strain, and Goodridge suggests stretching to keep back and neck muscles flexible. A lumbar support for the lower back automatically corrects upper body posture, she says.
A daily, hour-long exercise plan may not be one size fits all. For busy working adults, Goodridge recommends a regular walking program consisting of a 10-minute, lunch-hour walk to keep muscles loose and limber, invigorate blood flow, and help prevent low back problems.
Beyond posture and exercise, what we consume also contributes to health. Drinking six to eight glasses of water daily keeps the body hydrated, helps maintain muscle fluidity, and helps keep electrolytes in balance, Goodridge says, noting this balance can help to ease pain and heal soft-tissue injuries. Ice and heat therapies can be valuable therapeutic role players. For acute injuries, Goodridge generally recommends applying ice only for the first 72 hours, before applying heat. Ice should be applied twice a day for 10 minutes, or it may be applied up to once an hour for those who are very sore, she says.
BACK TO THE FUTURE
Clients who have recovered from prior injuries sometimes ask Goodridge to suggest a personal program for injury prevention rehab to carry them beyond clinical visits. “Sometimes you get a client who says, ‘I hurt my back and it’s fine now, but I don’t want it to happen again,’ ” she says. To design a personal plan for clients, Goodridge performs a full clinical assessment and targets deficits in a client’s range of motion, muscle strength and flexibility, posture, and gait. “A lot of people have impairments and deviations in their posture, or their gait, or muscle imbalances. It hasn’t come out to be an injury, but over time it will give them pain,” she says. Goodridge offers strategies, often meeting clients’ needs in two or three visits. She furnishes an exercise regimen, and on return visits she adjusts the program to meet the client’s evolving needs over a full course of treatment.
PURSUING A WELLNESS/FITNESS NICHE: 76 MILLION
“You have someone who comes in as a patient, but you never discharge them—so once they’re better, they can move into a different niche, into the health and wellness part of your practice,” Goodridge says. Patients can proceed along a continuum of care rather then starting over at another facility or clinic. “If we’ve incorporated Pilates into their treatment program and they want to continue with Pilates, they can continue it at our facility. The [Pilates instructor] they see can work with their therapist, who’s familiar with their situation.”
Some clients are pain free and need exercise advice. PTs perform a fitness assessment and furnish a home exercise program, which may include tips for gym workouts. Clients return periodically as their needs change. Other niche services include stress management, therapeutic massage, sports massage, and wellness coaching.
A potential problem for clients who are trying to trim expenses is that insurance does not currently cover the costs of wellness/prevention programs, but there may be a silver lining for PTs. “Nowadays, for so many people, insurance companies are cutting back so much that physical therapy on its own for a lot of people is costing them out of their pocket anyway,” Goodridge says. Things may change over the next few decades as the medical needs of Baby Boomers weigh more heavily on the health care system. Physical therapists who offer wellness and preventive health services may be paving the way to the changing health care needs of the future.
Judy O’Rourke is the associate editor of Rehab Management. For more information, contact .