I have just completed the first week of my Geriatrics placement at SCGH (Day Hospital). The placement requires us to see elderly patients in an outpatient setting, with the goal of keeping them safe and as independent as possible. I (aswel as the other students) have found it very surprising how little you actually need to do for them to achieve that goal. Specifically, I was surprised at the minimal amount of repetitions that our supervisor wants us to prescribe for a strengthening program.
I was treating an elderly lady, who has had some recent falls, for her weak knee & hip extensors and hip abductors, and decreased walking endurance. Part of my treatment involved me assessing how many sit to stands and clams she was able to do before becoming fatigued. She could do 8 and 10 respectively, so based on this I was going to prescribe her glut strengthening program. At uni we were taught the classic exercise physiology principles (60%-80% 1RM, 8-10 x, 3x sets...). I am quite aware that these are subject to modification, obviously depending on your patients ability, physical condition, PMHx ect. For this lady I would have given her 8-10 reps to do 3 x throughout the day (due to her age and co-morbidity's, I did not want her to do the 3 sets consecutively, so as not to over fatigue her, and would instruct her that she did not have to do all of them if she felt too tired or unwell). However, my supervisor said I must give her only 5 reps to be done 1x daily.
I did as my supervisor said and I pondered how this could possibly have any physiological effect on her muscles, as she did not seem that severely deconditioned, and she was very cognitvely there, and eager. I eventually mentioned this to my supervisor and she explained that in the elderly population you must always start conservatively, so as to prevent them from 'over doing it'. She gave me the example that if I did give the theoretical prescription, I could flare up a patient's underlying back pain, or they may actually do more than prescribed due to poor memory, therefore its best to give them less. Also, this patient, like most of all the other patients, function at very low fitness levels, and a seemingly minor increase in physical activity for us, could be enough to fatigue a patient enough to stop them being able to complete their ADLs. The key is to start small and then you have somewhere to progress to, rather then over working them, causing possible pain or more fatigue, which will just prolong their rehab.
I feel this was probably a case of theory vs. experience, but I am still not 100% convinced so I look forward to the rest of my placement,to see how my patients progress. In any case, it has definitely made me more aware of how important it is to tailor your treatment to your patient, and that your text book will not tell you everything!
3 comments:
My 2 week and 3 week placements were both geriatrics placements. I found that it does work better to prescribe less, at least until you know the patients personality. If too motivated you'll love them but they can overdo it like your supervisor said. They can also be the opposite and giving them too much can make them give up and say they're too tired or don't have time. Once you know the patient it is a lot easier to prescribe exercises.
When I was on geriatrics prac in SCGH the other student prescribed 3 sets of some knee exercise to this patient, and the next day the daughter called in and said their dad/mum(the patient) was bound to bed(knee pain) because of the exercises. So I think its best to start with less and progress it later when you know how they cope.
The comment your supervisor made, makes sense. In addition to the reasons your supervisor gave, I would guess it also increases the compliance of the patient. The patient only needs to do 5 reps a day, and the exercise will not increase their pain.
A similar incident happened when I was on my musculo placement. The patient presented with neck pain, which was treated by a PAIVM (unilateral L C5/6 and a central C2). The supervisor advised not to prescribe any range of motion exercises (neck rot/LF) on that treatment session. The reasoning behind it was to see if the PAIVMs had a lasting effect on the patient’s pain (the PAIVMs decreased the patient’s neck pain substantially). Another reason was to prevent any exacerbation of the pain, which could be the result of the ROM exercises.
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