12/13/2016. Manual Therapy in the Aging Population - It's Never Too Late! Session Description

Transcription

1 We are talking about aging from the patient s perspective Manual Therapy in the Aging Population - It's Never Too Late! Cameron W. MacDonald Saifulla Mirza Marcia B. Smith This is not to exclude the aged PT. but we may just not wish to have that conversation! Session Description This session will review the fundamental use of manual therapy interventions in the aging population, in any setting. A review of evidence-based interventions that are both patient- and condition-specific will be completed, with primary emphasis to the spinal column, hips, knee, and thoracic spine. Instruction for application for the entry-level to the experienced clinician will be reviewed. Attendees will learn about mobilization and manipulative interventions, as well as indications, precautions, and specific exercise additions to the targeted and regional manual therapy interventions. The speaker will provide a healthy dose of the historical utilization of manual therapy interventions in physical therapist practice. A tangent to address the current consequences of ineffective non-pharmaceutical care will be undertaken. The take-home message: You can do this, you should be doing this to optimize patient outcomes. Learning Objectives Upon completion of this session, you will be able to: Identify and interpret the current evidence base for manual therapy interventions in the geriatric population. Integrate concepts for manual therapy management into a patient-centered treatment plan to address orthopedic and neurological geriatric patient impairments. Validate the utilization of manual therapy interventions throughout the life span for the management of a broad range of conditions. Be familiar with the key research supporting manual therapy in the hip, spine, shoulder, and knee in the aged population. Session Format 5 min - Introduction 15 min - Manual Therapy indications geriatric population 15 min - Manual Therapy lumbar spine impairments 15 min - Manual Therapy hip impairments 15 min - Manual Therapy thoracic and shoulder impairments 15 min - Exercise incorporation to support manual therapy interventions 20 min Case Series Presentation 15 min - Select techniques for special populations/settings in aged care 5 min - Questions Aging, are not we all? For the purposes of this presentation the aging patient is considered to be 50 years of age or older I understand we could debate this a lot, but for the sake of getting along This is not based upon an AARP definition. Maybe we could draw on another the particular period of life at which a person becomes naturally or conventionally qualified or disqualified for anything 1

2 Is this Eugeric? (natural aging) Is this going to happen to everyone? Considerations in Aging Not just time. Or is it pathogeric aging? Boutry N, Paul C, Leroy X, Fredoux D, Migaud H, Cotton A, "Rapidly Destructive Osteoarthritis of the Hip: MR Imaging Findings" (AJR 2002; 179: ). Age related joint changes: The articular cartilage extracellular matrix and cell function within the cartilage change with age Tendons stiffen and lose compliance to demand Healing is slowed when joint injuries occur Important factor in the development and progression of osteoarthritis is chondrocyte (cartilage cell) degradation We need to avoid the conditions which promulgate chondrocyte death to retard osteoarthritis progression and preserve tissue homeostasis Grogan SP, D'Lima DD. Int J Clin Rheumtol Apr;5(2): Further considerations with age related joint changes Difficult to establish if changes are due to deconditioning, disease or eugeric Peak bone mass at years, then a progressive decline Cartilage thins, bones enlarge, facet hypertrophy Changes to joints are not in isolation: muscular and nervous system (muscle sarcopenia, slowed nerve conduction with myelin changes) Muscle changes starting around age 30 (less responsiveness to demand, stiffness, loss of flexibility) accentuates changes in joints in terms of functional consequences Bottom line promote the healthiest environment in which to function in, one being maintaining enough joint mobility and tolerance to load to best function Nair KS. Aging Muscle. Am J Clin Nutr. 2005: 81: Common Pathologies Osteoarthritis - OA Rheumatoid Arthritis - RA Lumbar stenosis central and foraminal Images Osteoarthritis (OA) vs Rheumatoid arthritis (RA) OA cartilage loss, mechanical wear and tear of the joint RA synovial lining inflammation, true disease process, multiple body tissue and organs effected Differentiation Duration of morning stiffness. OA up to 1 hour, RA beyond one hour. (generally) Also RA presents with joint inflammation, multiple joints, hand and foot deformity Images 2

3 Why is it important to differentiate? Manual therapy is strongly supported with individuals suffering mobility impairments with osteoarthritis, we will see this a lot in the research by region No such recommendation exists for rheumatoid arthritis only case reports Osteopenia v Osteoporosis Osteopenia BMD loss SD below aged matched normal Osteoporosis - BMD loss > 2.5 SD Fracture risk different, with a much more significant risk factor with osteoporosis Consider age effect due to matching versus normal not absolutes Osteoporosis is close to normal with aging (35% female >80) Image: Osteoporosis - Statistics 44 million in USA, or 55% of all people over 50 years of age (2006) >200 million people world wide 10 million osteoporosis and 34 million osteopenia 8 million women, 2 million men (4:1) 1 in 3 women will fracture in their lives post osteoporosis, 1 in 5 men Is manual therapy dangerous with osteoporosis? Manual Therapy Aging Population Manual Therapy Considerations in the Aging/Geriatric Population 3

4 Osteoporosis Manual PT? Severe Osteoporosis Sran & Khan 06 Khan study on thoracic spine fracture thresholds (Spine 2004) Mobilization load quantified at 145 Newton's to Thoracic Spine (T5-8) in vitro Load required to Fracture cadaveric bone TS SP s (77yrs) was 479 Newton's Results suggested a reasonable safety margin between in vitro loads and in vivo loads for oscillatory mobilizations Case study demonstrating the safe use of spinal manual PT with severe Osteoporosis (non-traumatic spinal compression fractures in Hx) Glucocorticoid induced secondary osteoporosis (similar risk to prednisone >2.5 mg daily) Considered thrust as contra-indicated (what does that word mean?) 10 sessions grade III-IV mobilizations Clinically significant outcomes (less pain more sleep) No change in radiographic presentation at 4 months 45% of PT s in British Columbia use Manual PT in Osteoporotic patients (46% e- stim) (Sran 05) Are some areas more at risk? Osteoporosis Technique Modifications Case reports of cervical spine fractures with spinal manipulation and osteoporosis Pathological Cervical Fracture after Spinal Manipulation in a Pregnant Patient. Journal of Manipulative and Physiological Therapeutics, Volume 28, Issue 8, Pages A. Schmitz, G. Lutterbey, L. von Engelhardt, M. von Falkenhausen, M. Stoffel Osteoporotic fracture of the Dens revealed by cervical manipulation Journal of Joint Bone & Spine, 71: , 2004 Hang-Korng Ea, Anne-Joelle Weber Common sense strategies in lumbar spine, pelvis and hips Distraction and gapping versus closing and compressive techniques Screening of all patients through History and examination Consider the final goal of the management versus immediate interventions strategy, chronic v acute presentation A cavitation may not be an ideal treatment goal, improved motion and exercise performance for functional gain is. Osteoporosis What not to do Osteoporosis What to do as a PT Disable by fear both the patient and the therapist (modify a manual technique, do not abandon hands on care due to fear) Fail to spread the load use broad contacts Fail to educate patient on their key role in self management, and of the efficacy of preventative strategies Fail to be a patient advocate and get them moving Restore joint and tissue mobility so: Weight bearing exercise can occur Pain is decreased allowing a greater participation in exercise and IADL Theoretically improved tissue and joint nutrition and decreased negative effects of immobilization will occur Structure exercise and measure outcomes 4

5 Manual Therapy Indications Geriatric Population In your clinic! No primary absolute contra-indications No other best choice Patient consent You know what you are doing Primary diagnosis arthritis, post surgical, chest mobility restrictions, impaired walking, spinal pain, joint pain etc. Manual Therapy Options Graded mobilization up to and including manipulation Muscle-energy techniques Positional modifications Soft tissue mobilizations Newleafphysiotherapy.com Lumbar Spine Stenosis LBP Manual Therapy Aging Population Lumbar Spine DJD/DDD Life! avoid the alternative Surgical versus nonsurgical interventions in spinal stenosis Surgical versus Nonsurgical Short term and long term outcomes Nonsurgical interventions can significantly improve patients outcomes Avoid potential adverse effects of invasive management strategies Outcomes of both are about the same in the long term 5

6 Stenosis Interventions Unloaded treadmill walking program Manual physical therapy Lumbo-Pelvic Region Lower Extremities Lumbar Stabilization Exercises Manual Therapy in the lumbo-pelvic region Statistically 4 out of 10 people in this room have some form of low back pain 65% of patients report dissatisfaction one year post reporting low back pain Only 7-10% get to a PT to manage the condition! Select slides courtesy of Julie Whitman PT DSc Low Back Pain Epidemiology 1 in 4 suffer with chronic LBP Back pain accounts for approximately 50% of all patients treated in outpatient PT practices Deyo and Weinstein. NEJM The other consequences of not providing interventions and management 6

7 SETTING Data extracted from Mercer Health Online a database of members of employee-sponsored health plans. PATIENTS 32,070 patients with a new primary care consultation for LBP from November 1, January 31, Substantial reduction in high cost procedures was noted. Physical therapy was underutilized, only 7% of patients received PT within 90 days. and in late 2016 it is 10% Early PT (within 14 days of primary care) occurred with 53% of physical therapy utilizers This decreased risk of advanced imaging, additional physician visits, lumbar surgery, lumbar injections, and opioid use as compared with delayed physical therapy. Early access to PT management for LBP, significant benefit for patient, significant reduction high cost procedures. Total medical costs for LBP were $ lower for patients receiving early physical therapy. PT 1 st OPIOIDS LAST PT 1 st OPIOIDS LAST Overdose Deaths per 100,000 Coloradoans 7

8 Considerations in LBP management People with LBP do not get better spontaneously in four weeks! The natural history is positive but misleading 95% recover by 12 weeks 40% relapse within 6 months This is the role of spinal motor conditioning and restoring function Epidemiology of LBP A prospective trial noted that while 90% of subjects consulting general practice with low back pain ceased to consult about the symptoms within three months, most still had substantial low back pain and disability. - Croft et al., 1998 Recovery or deconditioning? Croft et al (British Medical Journey, 1998) 490 individuals consulting GP with LBP 92% discontinued consultation within 3 months Only 25% had fully recovered within 12 months George (2012) LBP disability predictors: smoking, education level, female also previous injury and physical health status 4-8 weeks Is the situation improving? Deyo et al. J Am Board Fam Med What do we do currently when we get involved (7-10%)? Which manual therapy interventions should we use for patients with lumbar spine complaints? Direct spinal interventions, hip and pelvic interventions show the best benefit No new information, Mellin G in 1988 noted the strong correlation between LBP with hip extension and flexion mobility restrictions in 476 patients 8

9 If we were in a lab session here is what we would work on: Modification options for the larger patient Restoring Upright Posture (Overcoming Gravity) Manual Therapy Aging Population Hip/Pelvis Anterior Hip Tissue Influences for LBP Hip/Pelvis Hip OA Joint stiffness (neurological impairments) Gait difficulty LTPS (trochanteric bursitis) Anterior region of the hip is a very common place to develop tissue restrictions and lose the ability to stand upright. 9

10 Evidence supporting manual therapy for the aged patient in the hip and pelvic region A lot on the hip, minimal for the pelvis (in isolation) There does appear to be a relation between the hip and pelvis though! How many of these do you treat? What about Hip Osteoarthritis? Arthritis -$100 billion annually 10-20% of geriatric population Predictor of disability: 4 th most frequent in women, 8 th in men THA & TKA getting close to a million a year Inefficient single leg loading repeated many many times Reported etiology of OA in the Hip As part of the ambulatory health care population, 25-30% people over age 45 suffer from symptomatic hip OA Numbers as per the CDC for 2010 No current primary causes of hip osteoarthritis Secondary causes include - hip dysplasia, CHD, FAI, SCFE, Perthes disease, congenital coxa vara, labral tears 2 cause - altered mechanical force on hip 10

11 Pathology of Hip Osteoarthritis PT for Hip OA Hoeksma 2004 Increased intra-articular pressure, loss of chrondocyte nutrition Collagen breakdown in matrix, deep horizontal fissures Joint space loss Osteophyte formation Cartilage death/thinning and increased stiffness Subchondral sclerosis, osteophytes, bone cysts RCT, n = 109, 29 week follow-up Clinically meaningful improvements (pain, ROM, 6 months Rx: Long axis manipulation + stretching Recent Research Hip Manual Therapy Wright 10,13 Symptom reduction with hip distraction during evaluation suggests a positive response to treatment, but is not conclusive MacDonald 15 Clinical review effectives manual therapy for hip OA mature adults French 11 Sys Rev silver level evidence for manual PT for Hip OA Abbott 09,12-15 Hip OA trials comparing MPT to exercise underway, some completed Bennell 2013 Hip OA MPT vs. exercise Brantingham 10 Case series 18 Hip OA patients very good response to manual PT Thomas 10 Pre THA benefits with manual therapy pre THA consider improved pre-op training responses Cibulka 16 Clinical practice guidelines for management hip OA Abbott 13 Manual therapy provided by PT s for patients with Hip OA provided benefit sustained to one year over usual care directed by patient s MD or other provider Interventions included interventions similar to those to be presented today and home self mobilization three times per week Exercise also helped but combination slightly antagonistic (too much same day?) French 13 Manual therapy in addition to an exercise approach provided no additional benefit No manual therapy only group Less intense interventions do not provide a significant effect Consider the antagonistic effect noted in the Abbott trial Patient satisfaction higher with manual therapy included Which techniques for the hip (and to help the knee)? Intense enough to offer the potential of tissue change Within pain tolerance Goal to better tolerate weight bearing and share the load Not on the same day as intense exercise 11

12 More techniques at the knee joint Knee OA management with myofascial manual therapy Deyle Knee OA trial 05 noting the significant functional gains from a manual therapy approach Significant pain reduction and functional improvement reported Thoracic Spine/Shoulder They are a symbiotic team! RTC dysfunction Manual Therapy Aging Population Thoracic/Shoulder Thoracic stiffness/breathing impairment Shoulder DJD AC joint degeneration TS Aging and manual therapy Thoracic/regional manual intervention options (visual lab) TS pain increases from years of age then declines Safety as noted in the Khan and Sran articles is present with judicious decision making Interventions to the thoracic spine offer benefit form primary thoracic pain (30-40% prevalence in aged population), cervical, shoulder and post vertebral body fractures TS manual interventions also decrease shear and forces in the rest of the spine including those in patients in spondylolisthesis Shoulder RTC dysfunction: 50% age 50, 60% age 60 etc. 12

13 Key Exercises Considerations with Manual Therapy Manual Therapy Aging Population Complementary Exercise Approaches Load acceptance remember the breakdown of cartilage path Balance degrades with aging Proprioception degrades with OA progressions Task specific what do they wish to do? Tai Chi highly beneficial in the aged population Not antagonistic to the manual interventions received Lan % VO2 max gain one-year Tai Chi (58-70 years old) Exercise to compliment manual interventions House clinics UK Manual Therapy Aging Population Select techniques special populations Brian Schiff Blog Manual Therapy technique modification with elderly/aged population Positional changes needed Force changes Select opening vs closing techniques Shorter duration of interventions Avoid extension compression forces Be creative Immediate effects of thoracic manipulation on walking distance and lumbar spinal pain in geriatric patients with lumbar spinal stenosis Saifulla Mirza Cameron W. MacDonald Marcia B. Smith 13

14 Background Walking difficulty is a common problem in older adults which contributes to loss of independence, higher rates of morbidity and increased mortality. By 2030, nearly one in five U.S residents is expected to be age 65 or older Lumbar spinal stenosis (LSS) is a common cause of low back pain (LBP) and leg pain in individuals starting in the fifth and sixth decades of life which contributes to walking difficulty Interventions directed to the thoracic spine have been noted to be beneficial as a component of overall conservative management for patients impaired with lumbar stenosis 1, 2 Reduced walking speed is noted as a common problem in the geriatric and spinal stenotic population with significant impacts to function 3 Evidence supports the use of manual interventions for patients who have impairments with LSS (Whitman) Background Positive effects on pain & disability utilizing thrust & non thrust manipulation interventions in older adults with LBP have been reported 4 No research is noted that reviews the immediate effects of thoracic manual therapy on walking distance/speed in patients with LSS. Purpose The purpose of this case series is to report on the immediate effects on walking speed/distance of thoracic mobilization/manipulation in a subgroup of patients with LSS. Case Series Description Seated Thoracic Manipulation Six patients, three males & three females years old were treated in an outpatient setting. All had a medical diagnosis of LSS as part of their overall presentation. All patients demonstrated increased thoracic kyphosis and a positive history of walking difficulty. Patient s reported low back pain (LBP) ranging lumbar from 2-6/10 on the Numeric Pain Rating Scale (NPRS) except one patient who was asymptomatic for spinal pain but limited in walking function. All potential subjects were screened for relative contraindications including severe osteoporosis with written consent obtained. Supine Thoracic Manipulation Prone Thoracic Manipulation 14

15 Methodology Outcomes A six minute walking test (6MWT) was completed before and immediately after thoracic mobilization/manipulation. Graded central posterior-anterior (CPA) mobilizations were performed for four bouts of 30 seconds each in prone to mid thoracic spine. Thoracic manipulation was performed either in supine, prone or seated positions to mid thoracic spine, determined by the comfort of the patient. Five of six patient s received thrust manipulation. Immediate measures of walking distance noted an increased walking distance of an average of ± feet on 6MWT (95% confidence interval: p = 0.028) Spain decreased an average of 1.16 on NPRS immediately after thoracic mobilization or manipulation (not significant, p = 0.63). Four of six patients met the minimally clinical important difference (MCID) for the 6MWT 5. Discussion LBP pre-post scores: This case series suggests a potential immediate benefit for walking distance/speed in patients with LSS. A secondary small level of reduction in LBP was also noted. A cause and effect relationship cannot be inferred in this case series, but the results are promising and suggestive of a need for further inquiry on the effects of thoracic mobilization/manipulation in patients with LSS symptoms, and to ascertain the longer term effects of this approach. Immediate pain reductions with thoracic manual interventions for patients with symptomatic LSS were also noted in this study. Patient ages 70-82! Walking distance pre-post scores: Questions? 15

16 References 1 - Whitman, JM et al. Spine. A comparison between two physical therapy treatment programs for patients with lumbar spinal stenosis: a randomized clinical trial. 2006; 31(22): Backstrom KM, Whitman JM, Flynn TW. Man Ther. Lumbar spinal stenosisdiagnosis and management of the aging spine. 2011; 16(4): Schmidt CT et al. J Geriatr Phys Ther. Health Characteristics, Neuromuscular Attributes, and Mobility among Primary Care Patients with Symptomatic Lumbar Spinal Stenosis: A Secondary Analysis Mar Learman K et al. Physiother Can. No Differences in Outcomes in People with Low Back Pain Who Met the Clinical Prediction Rule for Lumbar Spine Manipulation When a Pragmatic Non-thrust Manipulation Was Used as the Comparator. 2014; 66(4): Wise RA & Brown CD. COPD. Minimal clinically important differences in the six-minute walk test and the incremental shuttle walking test Mar; 2(1): References 6 - Masaracchio M, Ohja H, MacDonald C. Thoracic Spine Manual Therapy for Aging and Older Individuals. Topics in Geriatric Rehabilitation, Volume 31, Number 3, MacDonald C.. Hip Manual Therapy for Aging and Older Adults. Topics in Geriatric Rehabilitation. Volume 31, Number 3, Peek A, Miller C, Heneghan N. J Man Manip Ther Sep;23(4): Thoracic manual therapy in the management of non-specific shoulder pain: a systematic review. 9 - Cleland J, Glynn P, Whitman J, Eberhart S, MacDonald C, Childs J. Phys Ther Apr;87(4): Short-term effects of thrust versus nonthrust mobilization/manipulation directed at the thoracic spine in patients with neck pain: a randomized clinical trial Courtney C, Steffen A, Fernández-de-Las-Pñas C, Kim J, Chmell S. J Orthop Sports Phys Ther Mar;46(3): Joint Mobilization Enhances Mechanisms of Conditioned Pain Modulation in Individuals With Osteoarthritis of the Knee Fritz J, Lurie J, Zhao W, Whitman J, Delitto A, Brennan G, Weinstein J. Spine J Aug 1;14(8): Associations between physical therapy and long-term outcomes for individuals with lumbar spinal stenosis in the SPORT study Whitman J, Flynn T, Childs J, Wainner R, Gill H, Ryder M, Garber M, Bennett A, Fritz J. Spine ;31(22): A comparison between two physical therapy treatment programs for patients with lumbar spinal stenosis: a randomized clinical trial. 16