Geriatric Physical Therapy, 3e

618 Pages·2011·34.48 MB·English

by  Andrew A. Guccione PT PhD DPT FAPTA

3251 Riverport Lane
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GERIATRIC PHYSICAL THERAPY, THIRD EDITION ISBN: 978-0-323-02948-3
Copyright © 2012, 2000, 1993 by Mosby, Inc., an affiliate of Elsevier Inc.
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Printed in the United States of America
Last digit is the print number: 9 8 7 6 5 4 3 2 1
Thrice again – for Nancy, Katie, and Nicole
Andrew A. Guccione
To my husband Al for his unwavering support and
encouragement; and to my children and grandchildren
who grow more precious every day
Rita A. Wong
To Patrick VanBeveren, my husband, partner and best
friend
Dale Avers

C O N T R I B U T O R S
Alia A. Alghwiri, PT, MS Cory Christiansen, PT, PhD Andrew A. Guccione, PT, PhD,
PhD candidate Assistant Professor DPT, FAPTA
University of Pittsburgh Physical Therapy Program Deputy Director
Physical Therapy Department Department of Physical Medicine Health Services Research
Pittsburgh, Pennsylvania & Rehabilitation & Development Service
School of Medicine Department of Veterans Affairs
Dale Avers, PT, DPT, PhD University of Colorado Washington, DC
Associate Professor Aurora, Colorado
Director, Post Professional DPT Greg W. Hartley, PT, DPT, GCS
Program Charles D. Ciccone, PT, PhD, Director of Rehabilitation &
Department of Physical Therapy FAPTA Assistant Hospital
Education Professor Administrator,
College of Health Professions Department of Physical Therapy Geriatric Residency Program
SUNY Upstate Medical University Ithaca College Director
Syracuse, New York Ithaca, New York St. Catherine’s Rehabilitation
Hospitals and Villa Maria
Katherine Beissner, PT, PhD Rhea Cohn, PT, DPT Nursing Centers
Professor Health Care Consultant Miami, Florida;
Department of Physical Therapy Washington, DC metro area Adjunct Assistant Professor
Ithaca College University of Miami Miller School
Ithaca, New York Joan E. Edelstein, PT, MA, FISPO, of Medicine
CPed Department of Physical Therapy
Diane Borello-France, PT, PhD Special Lecturer Coral Gables, Florida
Associate Professor Program in Physical Therapy
Department of Physical Therapy Columbia University Barbara J. Hoogenboom, PT,
Rangos School of Health Sciences New York, New York EdD, SCS, ATC
Duquesne University Associate Professor
Pittsburgh, Pennsylvania Cathy S. Elrod, PT, PhD Program in Physical Therapy
Associate Professor Grand Valley State University
Richard Briggs, MA, PT Department of Physical Therapy Grand Rapids, Michigan
Hospice Physical Therapist Marymount University
Enloe Medical Center, Hospice and Arlington, Virginia Catherine E. Lang PT, PhD
HomeCare Assistant Professor
Chico, California Christine E. Fordyce, PT, DPT Program in Physical Therapy
Rehab Director Program in Occupational
Marybeth Brown, PT, PhD, FAPTA Gentiva Health Services Therapy
Professor Auburn, New York Department of Neurology
Physical Therapy Program, Washington University
Biomedical Sciences Claire Gold, MSPT, MBA, COS-C, Saint Louis, Missouri
University of Missouri CPHQ
Columbia, Missouri Home Health Agency Administrator Tanya LaPier, PT, PhD, CCS
Gentiva® Home Health Professor
Sabrina Camilo, PT, MSPT, GCS San Diego, California Eastern Washington University
Private Practitioner Cheney, Washington
São Paulo, Brazil
vii
viii CONTRIBUTORS
Paul LaStayo, PT, PhD, CHT Jean Oulund Peteet, PT, MPH, PhD Chris L. Wells, PhD, PT, CCS,
Associate Professor Clinical Assistant Professor ATC
Department of Physical Therapy Department of Physical Therapy and Assistant Professor–Part Time,
University of Utah Athletic Training Department of Physical Therapy
Salt Lake City, Utah Boston University College of Health & Rehabilitation Science
and Rehabilitation Sciences– University of Maryland School of
Carleen Lindsey, PT, MScAH, GCS Sargent Medicine
Physical Therapist Boston, Massachusetts College Park, Maryland
Bones, Backs & Balance
Bristol, Connecticut John Rabbia, PT, DPT, MS, GCS, Karin Westlen-Boyer, DPT, MPH
CWS Intermountain Health & Fitness
Toby M. Long, PT, PhD, FAPTA Visiting Nurse Association of Institute at LDS Hospital
Associate Professor Central New York Salt Lake City, Utah
Department of Pediatrics
Director of Training Barbara Resnick, PhD, CRNP, Mary Ann Wharton, PT, MS
Center for Child and Human FAAN, FAANP Associate Professor and
Development Professor Curriculum Coordinator
Georgetown University Sonya Ziporkin Gershowitz Chair in Department of Physical Therapy
Washington, DC Gerontology Saint Francis University
University of Maryland School of Loretto, Pennsylvania;
Michelle M. Lusardi, PT, DPT, PhD Nursing Adjunct Associate Professor
Professor Emerita College Park, Maryland Physical Therapist Assistant
Department of Physical Therapy and Program
Human Movement Science Julie D. Ries, PT, PhD Community College of Allegheny
College of Education and Health Associate Professor County, Boyce Campus
Professions Program in Physical Therapy Monroeville, Pennsylvania
Sacred Heart University Marymount University
Fairfield, Connecticut Arlington, Virginia Susan L. Whitney, PT, DPT, PhD,
NCS, ATC, FAPTA
Robin L. Marcus, PT, PhD, OCS Kathleen Toscano, MHS, PT, PCS Associate Professor
Assistant Professor Pediatric Physical Therapist Program in Physical Therapy and
Department of Physical Therapy Montgomery County Infant and Otolaryngology
University of Utah Toddler Program University of Pittsburgh
Salt Lake City, Utah Olney, Maryland Pittsburgh, Pennsylvania
Carol A. Miller, PT, PhD, GCS Patrick J. VanBeveren, PT, DPT, Ann K. Williams, PT, PhD
Professor MA, OCS, GCS, CSCS Adjunct Professor
Doctorate Program in Physical Director of Physical Therapy Services College of Health Professions and
Therapy St. Camillus Health and Biomedical Sciences
North Georgia College & State Rehabilitation Center The University of Montana
University Syracuse, New York Missoula, Montana
Dahlonega, Georgia
Michael Voight, PT, SCS, OCS, Rita A. Wong, EdD, PT
Justin Moore, PT, DPT ATC, CSCS Physical Therapy Department
Vice President, Government and Professor Chairperson
Payment Advocacy School of Physical Therapy Professor of Physical Therapy
American Physical Therapy Belmont University Marymount University
Association (APTA) Nashville, Tennessee Arlington, Virginia
Alexandria, Virginia
Martha Walker, PT, DPT
Karen Mueller, PT, PhD Clinical Instructor
Professor Physical Therapy and Rehabilitation
College of Health and Human Science
Services University of Maryland
Department of Physical Therapy Baltimore, Maryland
Northern Arizona University
Flagstaff, Arizona
P R E F A C E
Although the content of previous editions has been sub- explore the personal and environmental contexts of ex-
stantially revised, it is remarkable that the overall pur- amination and intervention, particularly as these factors
pose of this textbook has not changed since the first provide nuance to examination findings or modulate the
edition 18 years ago. The editors’ intent for undertaking outcomes of intervention. Part III provides the scientific
the third edition of Geriatric Physical Therapy is to as- basis for evaluation and diagnosis of prototypical health
sist the development of reflective physical therapists who conditions and patient problems that are emblematic of
can use the available scientific evidence and objective geriatric physical therapy as well as the design of plans of
tools to integrate health and functional status informa- care for effective treatment and optimal outcomes. In the
tion with examination data, formulate an accurate diag- next section, the chapters cover some health conditions
nosis, and design effective treatment plans that can be that are not common to the entire population of older
implemented at all levels of care and across all settings adults but represent points of substantial health impact
to produce optimal outcomes. We further believe that requiring specific expertise to be addressed effectively.
this practitioner can serve both patients and society as an The practice of physical therapists in our application of
informed advocate for older adults. What has changed specific education, experience, and expertise in the health
throughout the years is that the original publication was problems of older adults across spectrum of healthcare
intended only as a textbook for entry-level students. In delivery is presented in Part V. Finally, the last section
the intervening years we have expanded the vision of this tackles the societal issues affecting physical therapist
text to include individuals studying for the examination practice that can propel or obstruct the profession’s abil-
to be certified as geriatric clinical specialist as well as ity to address the health of older adults and optimize the
practicing clinicians. The last group is perhaps the most health of the nation: reimbursement and advocacy.
surprising and the most gratifying. Geriatric physical What started as an attempt to update a well-received
therapy has come into its own in the last two decades. resource was infused with a new vision and turned
The emergence of the specialty, the growth of certified into a substantial revision to reflect the changes in geri-
specialists, and the number of practicing clinicians in the atric physical therapy and the profession itself in the last
area all attest to the fact that physical therapist practice 20 years. The goals which we first described in 1993 and
oriented toward older adults is no longer a novelty, con- repeated in the second edition remain: to define the sci-
fined to a few physical therapists whose good hearts and entific basis of physical therapy; to describe how physi-
intentions led them to concerns about America’s aging cal therapist practice with older adults differs from
population. On the contrary, geriatric physical therapy is physical therapist practice in general; and to promote the
bursting with innovation in practice and cutting edge adoption of evidence-based principles of clinical care
research that will enable physical therapists to exercise that advance geriatric physical therapist practice. It is
the full range of their education, experience, and exper- clear now that the best scientific thoughts are being
tise across the full continuum of the health care system translated into clinical actions. We are pleased to think
from primary prevention to end-of-life care. that we have contributed to this phenomenon.
The new edition of Geriatric Physical Therapy has
been arranged in six parts. In Part I, we organize the Andrew A. Guccione, PT, PhD, DPT, FAPTA
foundational sciences of geriatric physical therapy, which Rita A. Wong, EdD, PT
range from basic physiology of aging to clinical epidemi- Dale Avers, PT, DPT, PhD
ology of disease and disability. Next, our contributors
ix
x CHAPTER 12 Chapter Title Goes Here
A C K N O W L E D G M E N T S
This is truly a textbook that reunites an old team with to find each other then; we know now we were blessed
some long-term colleagues, but also introduces a sub- with an exciting intellectual partnership and profes-
stantial number of new contributors that allows us to sional friendship.
appreciate the vitality of geriatric physical therapy and We are indebted to Christie Hart for encouraging us
the profession itself. Their vibrant contributions, joined to undertake a third edition. While the response to the
with cutting-edge expertise, have expanded the horizons previous editions was very positive, we knew the scope
of this text and enriched us as professionals committed of geriatric physical therapist practice had evolved sub-
to practice with older adults. stantially necessitating a global revision. The team at
The editorial team exemplifies the essence of collab- Mosby/Elsevier has supported us each step of the way.
orative practice in geriatric physical therapy. As it hap- Ultimately, we recognize that whatever we might
pens, we had worked together before on what was, and know about geriatric physical therapy is the summation
still is, a professional career highlight for all of us: the of countless interactions with scientists, clinicians, edu-
development of the geriatric specialty examination. Dur- cators and students, but most of all our patients. It is in
ing that venture, our special contributor and friend, recognition of their primary role in teaching us as well as
Marybeth Brown, was a full member of the team. For our families in supporting us that this work is dedicated.
this venture, our “silent” partner in developing the ex-
amination, Dale Avers, switched places with Marybeth, Andrew A. Guccione, PT, PhD, DPT, FAPTA
taking the on-stage role while Marybeth contributed her Rita A. Wong, EdD, PT
singular expertise from the wings. It seemed fortuitous Dale Avers, PT, DPT, PhD
x
I
P A R T
Foundations
11
C H A P T E R
1
Geriatric Physical Therapy
in the 21st Century:
Overarching Principles
and Approaches to Practice
Rita A. Wong, EdD, PT
INTRODUCTION KEY PRINCIPLES UNDERLYING
CONTEMPORARY GERIATRIC PHYSICAL
This book promotes the reflective, critical, objective,
THERAPY
and analytical practice of physical therapy applied
to the older adult. All physical therapists, not just those
Evidence-Based Practice
working in settings traditionally identified as “geriat-
ric,” should possess strong foundational knowledge Evidence-based practice is an approach to clinical
about geriatrics and be able to apply this knowledge to decision making about the care of an individual patient
a variety of older adults. Indeed, older adults comprise that integrates three separate but equally important
at least 40% of patients across physical therapy clinical sources of information in making a clinical decision
settings.1 Although the fundamental principles of about the care of a patient. Figure 1-1 illustrates these
patient management are similar regardless of patient three information sources: (1) best available scientific
age, there are unique features and considerations in the evidence, (2) clinical experience and judgment of
management of older adults that can greatly improve the practitioner, and (3) patient preferences and moti-
outcomes. vations.2 The term evidence-based practice sometimes
This chapter starts with a brief discussion of the misleads people into thinking that the scientific
key principles and philosophies upon which the book evidence is the only factor to be considered when using
is grounded: evidence-based practice; optimal aging; this approach to inform a patient-care decision.
the slippery slope of aging; clinical decision making Although the scientific literature is an essential and
in geriatrics; the role of exercise and physical activity substantive component of credible clinical decision
for optimal aging; objectivity in the use of outcome making, it is only one of the three essential compo-
assessment tools; and the importance of patient values nents.2,3 An alternative, and perhaps more accurate,
and motivation. The chapter continues with a discus- label for this approach is evidence-informed practice.
sion of the geriatric practitioner of the future and The competent geriatric practitioner must have a good
mechanisms required to prepare adequate numbers of grasp of the current scientific literature and be able to
practitioners for this expanding role; it then moves interpret and apply this literature in the context of an
to the key principles of locating, analyzing, and individual patient situation. This practitioner must also
applying best evidence in the care of older adults. have the clinical expertise to skillfully perform the ap-
The chapter ends with a discussion of ageism and the propriate tests and measures needed for diagnosis, inter-
impact of ageism on health care services to older pret the findings in light of age-related and condition-
adults. specific characteristics of the patient, and then to skillfully
2 Copyright © 2012, 2000, 1993 by Mosby, Inc., an affiliate of Elsevier Inc.
CHAPTER 1 Geriatric Physical Therapy in the 21st Century 3
Best available evidence Brummel-Smith6 expanded the concepts of Rowe
and Kahn in the depiction of optimal aging as a more
inclusive term than successful aging. Brummel-Smith
defines optimal aging as “the capacity to function
across many domains—physical, functional, cognitive,
emotional, social, and spiritual—to one’s satisfaction
Patient
and in spite of one’s medical conditions.”6 This concep-
tualization recognizes the importance of optimizing
functional capacity in older adults regardless of the
Clinical Patient presence or absence of a chronic health condition.
expertise/judgment preferences and motivations
Functional limitations associated with chronic health
FIGURE 1-1 Key elements of evidence-informed practice.
conditions often lead to a vicious downward cycle with
increasing levels of disability leading to greater decon-
apply the appropriate interventions to best manage the ditioning that further decreases functional ability. These
problem. This is all done with clear and full communica- declines lead to secondary conditions associated with
tion with the patient to assure the goals and preferences chronic conditions and, often, to additional new dis-
of the patient are a central component of the develop- eases. Physical therapists can be particularly instrumen-
ment of a plan of care. tal in reducing the disabling effects of chronic disease
processes by promoting restorative and accommodative
changes that stop or reverse the vicious downward
Optimal Aging
functional cycle, allowing the individual to achieve
Rowe and Kahn4 first introduced the terms successful optimal aging in the presence of chronic health condi-
and usual aging in the mid-1980s as a mechanism to tions.
remind practitioners and researchers that the typical
changes in physiological functioning observed in older
Slippery Slope of Aging
adults (usual aging) are quite variable and generally
represent a combination of unavoidable aging-related Closely linked to the concept of optimal aging is the
changes and modifiable (avoidable) lifestyle factors such concept of a “slippery slope” of aging (Figure 1-2).
as physical activity, nutrition, and stress management. The slope, originally proposed by Schwartz,7 represents
Their perspective encourages practitioners to consider the general decline in overall physiological ability (that
that for many older adults, a substantial proportion Schwartz expressed as “vigor”) that is observed with
of apparent age-related changes in functional ability increasing age. The curve is arbitrarily plotted by decade
may be partially reversible with lifestyle modification on the x-axis so the actual location of any individual
programs. along the y-axis—regardless of age—can be modified
Ten years later, Rowe and Kahn5 provided further (in either a positive or negative direction) based on
clarification of the key components that make up their
model for successful aging. The specific elements they
present as the signs of an individual who is aging success- 100
fully are (1) absence of disease and disability, (2) high 90
cognitive and physical functioning, and (3) active engage-
80
ment with life. Rowe and Kahn describe a usual aging
syndrome as one in which suboptimal lifestyle leads to nt) 70 Fun
e
chronic health problems that affect function and thus the erc 60
atibesil.i tIym tpor orveiandgi lhy eeanltghayg eli fiens tfyalem iisl ye nocro cuoramgmedu nasit ya macetaivnis- Vigor (p 5400 Function
of achieving successful aging.
30
Although helping older adults avoid disease and Frailty
disease-related disability is a central consideration for all 20
health care practitioners, the reality is that the majority 10
Failure
of older adults do have at least one chronic health condi-
20 100(cid:31)
tion and many, particularly among the very old, live with
Age
functional limitations and disabilities associated with
the sequela of one or more chronic health conditions. FIGURE 1-2 Slippery slope of aging depicts the general decline in
overall physiological ability observed with increasing age and its
For this large group of individuals, Rowe and Kahn’s
impact on function. (Adapted from Schwartz RS: Sarcopenia and
model needs to stretch beyond the concept of avoidance
physical performance in old age: introduction. Muscle Nerve
of disease and disability. Suppl5: S10-S12, 1997.)