The Fragile State of Function in Persons Aging with a Disability Lilli Thompson, P.T.

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The Fragile State of Function in Persons Aging
with a DisabilityLilli Thompson, P.T.
Research Associate, Rehabilitation Research and
Training Center on Aging with a Disability
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Rehabilitation Research and Training Center on
Aging with a Disability
Rancho Los Amigos National Rehabilitation
Center University of California, Irvine
Funded by the National Institute on Disability
and Rehabilitation Research
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Rehabilitation Research and Training Center on
Aging with Spinal Cord Injury
Rancho Los Amigos National Rehabilitation Center
Funded by the National Institute on Disability
and Rehabilitation Research
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The Interaction of Physical, Psychological, and
Social Factors Increases With Age Disability
Physical
Psychological
Function
Social
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Aging and Functional Capacity
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Aging and Functional Capacity
Non- SCI 1 per year
SCI 1.5 per year
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Common Additional Changes in Persons with a
Disability
SYSTEM PHYSIOLOGY ___
IMPAIRMENT
Musculoskeletal Sarcopenia
Strength Degeneration Joint
dysfunction of articular
surface Osteoporosis Fracture risk
Spinal deformity Pulmonary
balance Pain Neuromuscular
Entrapement Pain weakness
neuropathies Central NS
Syringomyelia Weakness, pain
Tethered cord sensory loss Cardiovascular
Max cardiac output Tolerance for
Max heart rate physical
activity Pulmonary V02 Max
Vital capacity Integument
Fragility Decubitus ulcers
Subcutaneous fat
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FUNCTIONAL ACTIVITIES AT RISK

• MOBILITY
• SELF - CARE
• TASKS / CHORES
• WORK / SCHOOL
• SOCIAL ACTIVITIES
• RECREATION
• LIFE ROLES

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Percent Indicating a Decline in One or More ADLs
or IADLs by Group Over a 10 year Duration
n 497
Avg age 55

Avg age 57
RRTC on Aging with a Disability, Natural Course
of Aging with a Disability Study, 2002
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Percent With At Least One ADL Decline By Age
Impairment group Control group

Age
plt.001
RRTC on Aging with a Disability Natural Course of
Aging with a Disability Study, 2002
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Ambulation in Adults with Cerebral Palsy
n60
Stopped by Age 30
Continue Ambulating

• fatigue
• inefficiency

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56
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Stopped by Age 50

• pain
• fatigue

Murphy K, Molar GE, Lankasky K. Medical and
functional status of adults with cerebral palsy
Dev Med Child Neuro. 1995, 37, 1075-1084.
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Employment Changes
Polio Of 539 polio survivors, over half were
having to make major alterations in their
lifestyle and even change jobs to minimize the
impact of new health and functional problems with
aging (Halstead Rossi, 1985). Agre et al
(1989) found 46 of 79 post polio patients had
difficulty continuing to work due to new health
and functional problems. Einarsson Grimby
(1990) report 39 of forty-one polio survivors
retired early due to the functional consequences
of post-polio syndrome. CP Murphy et al. (2000),
53 of 101 adults with CP were gainfully
employed. Education (gt HS) and resolving
mobility issues were important factors in
achieving employment. Of the nonambulatory group,
86 used a power w/c for work, but over half
were independent with manual mobility (
efficiency greater mobility)
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Common Symptoms Associated with Functional Change

• Pain
• Weakness
• Fatigue

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OUCH!
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PAIN
Unpleasant, uncomfortable sensory experience
associated with potential tissue damage

• Acute Pain
• Chronic Pain

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Incidence of Pain by Impairment Group
n 337
Severity mild mod/severe

(120)
(23)
(60)
(9)
(125)
RRTC on Aging with a Disability Natural Course of
Aging with a Disability Study, 2002
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Degree that Pain Interferes with self-care by
Age and Group
Score
plt.001
Age
RRTC on Aging with a Disability Natural Course of
Aging with a Disability Study, 2002
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Unresolved UE Pain
Conditioning Strength Endurance Weight gain
Activity
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YAWN!
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FATIGUE

• Overwhelming sense of tiredness or lack of energy
• Abnormal when
• Fatigue levels are greater than expected based
  on activity level or
• Fatigue lasts longer than expected (ie. 2 weeks
  
• without a known cause)

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Incidence of Fatigue by Impairment Groups
n 351

Polio
CP
SCI
Control
RRTC on Aging with a Disability, Natural course
of aging with a disability study, 2001
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Degree Fatigue Interferes With Work, Family, and
Social Life By Age And Group
Score
plt.001
Age
RRTC on Aging with a Disability Natural Course of
Aging with a Disability Study, 2002
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Every decision about an activity . . . well,
really every aspect of my life, must first filter
through the question of whether I have enough
energy to do it and then how much am I going to
pay for doing it.
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FATIGUE CAUSING CONDITIONS
Disrupted Sleep Medication Side
Effects Depression Chronic Hypoventilation Chronic
Infection (UTIs, decubitti, etc.) Hypoxemia Syst
emic Disease (Diabetes, Hepatitis, SLE,
etc.) Heart Failure Thyroid Disease Anemia Canc
er
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Regional and Total Body Lean Tissue Comparisons
Lean Tissue
Bauman WA, Spungen AM. Body composition in aging
Adverse changes in able-bodied and in those with
SCI , Top Spinal Inj Rehabil. 2001 6(3) 22-36.
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Annual Fall Rates for Polio, CP, and Nondisabled
Groups

1 fall
2 - 5
6 - 12
14 - 24
365
Fall/year
RRTC on Aging with a Disability Natural Course of
Aging with a Disability Study, 2002
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Walking Cessation by Age in CP Group
n 27

• Stopped by 30 due to
• fatigue
• inefficiency

Stopped by 50

• pain
• fatigue

11 - 20
21-28
38-50
gt60
Murphy K, et al. Dev Med Child Neuro. 1995, 37,
1075-1084.
AGE
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When Function Changes Occur Who Provides
Assistance?
n 150
ADLs IADLs

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Assistive Technology Studyn25
AT categories mobility, splint/braces, DME,
low-tech, home accommodations self reported
problems 2 in-home evaluation 7
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CONSUMERS LIVINGWITH THE ISSUES OF AGING WITH A
DISABILITY WANT THE ANSWERS
NOW!
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Patient Client Management

• Comprehensive versus problem specific
  examination
• Look for the key markers
• Symptoms associated with risk of functional
  decline may
• precede actual changes (new pain, fatigue,
  weakness, etc.)
• Key examinations
• Functional performance
• Musculoskeletal
• Neuromuscular
• Equipment
• ASK! WATCH! LISTEN!

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Interventions
So . . . what do we do now?
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Take a good hard look at these issues

• How are activities performed?
• What type of equipment is used?
• Does it optimize function?
• What equipment changes or changes in
• movement mechanics can be made to
• optimize function?

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INTERVENTION Starts with PREVENTION
Recognize the impact early rehabilitation
decisions and processes have on later life issues
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Example of Typical Daily Functional Demands for
W/C users
To bed - Sleep?
Household chores
Exercise?
Outings (work, school, social, community chores,
recreation)
Propulsion (hills, rough terrain, ramps, curb
cuts, distance)
Transfers (cars, chairs, toilets,
bathbench, couches, floor, bed)
Bathing/Toileting/Dressing/Pressure relief raises
Rise and Shine -Up and out of bed!
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Evaluating Weakness

• Manual Muscle Testing
• Functional Performance Assessment - Mobility
• - Activities of Daily Living

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Management of Weakness

• Strengthen (when and what is appropriate)

• Beware of exacerbating overuse syndromes.
• Use muscle response as a guide
• loss of force production or muscle belly
  tenderness
• BACKOFF!
• Work to achieve appropriate strength
  relationships between
• muscle groups.

• Support joints around weakened muscles

• Modify activities

• Improve efficiency
• Decrease energy cost

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SHOULDER EXERCISES
Strengthening Scapular Retraction External
Rotation Adduction Stretching Pectoralis
Stretch Biceps Stretch
Curtis KA, et al. Spinal Cord 37, 421-429 (1999)

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Pain FatigueManagement Strategies
Identify medically-based causes and treat these
appropriately Lifestyle management
(pacing) Assistive Technology Medication
PAIN
FATIGUE
Postural corrections Modalities (heat, ice, TENs
etc.) Medication Therapeutic exercise Pain
management program
Introduce energy conservation tools Improve
efficiency of movement Prioritize activities
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Mobility Decisions
Mobility Decisions
Ambulation
Ambulation
, W/c Propulsion, Powered Mobility
, W/c Propulsion, Powered Mobility
The primary means of mobility should not be the
means for exercise.
The primary means of mobility should not be the
means for exercise.
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New Work Related Problems for Persons Aging with
a Disability
n 90
Workers experienced diminished functional
abilities, increased pain and fatigue with
advancing age and impairment duration. These
changes resulted in needs for new job
accommodations.
Typical Types of Problems Use of
equip/tools/furniture Access (esp. parking
restrooms) Task performance Common Interfering
Symptoms Pain Fatigue
McNeal DR, Somerville NJ, Wilson DJ. 1999. Work
problems and accommodations reported by persons
who are postpolio or have a spinal cord injury.
Asst Technol. 11137-157.
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Job Accommodations

• Types of accommodations
• Adapting work environment
• Providing special equipment
• Modifying the job
• Reassignment of duties or roles
• Retraining for different duties or
  responsibilities
• Co-worker assistance

• Costs
• Over 50 of accommodations cost nothing
• 30 cost lt 500
• Employers stated the benefits outweighed costs

McNeal, Somerville, Wilson, (1999). Work problems
and accommodations reported by persons who are
postpolio or have a spinal cord injury. Assist
Technol. 11137-157
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Energy Cost of Ambulation
02 rate decrease linearly related to the AMI
02 Rate ( Normal)
(Ambulatory Motor Index reflects degree of
impairment of LEs)
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20
60
80
100
AMI ( Normal)
02 Cost linearly related to the AMI
Waters Rl, et al. Gait performance after SCI.
Clin Orthop Rel Res. 199387-96.
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Thank You !
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Implications for Clinical Practice

• Lilli Thompson, PT

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Most Any Clinical Practice Setting Will Have
Patients/clients Facing These Issues!

• Acute Care Hospitals
• Outpatient Clinics
• Rehabilitation Facilities
• Skilled Nursing
• Industrial Vocational Worksites

• Home Health
• Education Research Centers
• Schools
• Athletic Facilities
• Fitness Sports Training Centers

Etc.!
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INTERVENTION Starts with PREVENTION
Recognize the impact early rehabilitation
decisions and processes have on later life issues
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Initial Rehabilitation focus

• Recognize the value of education about
  long-term life issues. Initial rehab may be the
  only teachable moment.
• Assist with finding the balance between the
  need for exercise and the need for efficient
  movement.
• The primary means of mobility should not be the
  means for exercise.
• Emphasize performance skills that protect the
  musculoskeletal system and provide the rational
  for specific performance techniques.
• Educate clients about potential changes and how
  to recognize and respond to symptoms associated
  with functional change.

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Long-Term Life Perspectives In Rehabilitation
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Strive For The Cumulative Effect Of Small Changes
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RECOMMENDATIONS

• Do not overly accept change as just normal
• Thoroughly evaluate changes in health and
  function
• Strive for a partnership between healthcare
  provider and client
• Prioritize activities and attempt incremental
• changes