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Age isn't everything, but it does count for something when it comes to manual therapy. And when considering whether massage or other techniques are appropriate for certain patients, many physical therapists find they need to make allowances for age-related factors.
"You always have to modulate your treatment selection according to the population you're working with," explained Chad Cook, PT, PhD, MBA, OCS, FAAOMPT, assistant professor of physical therapy at Duke University in Durham, NC. "If you have a frail older woman, you're going to be more cautious about the technique you use."
However, many physical therapists assume that the thin tissue in older patients means they can't handle manual therapy, and that's unfortunate.
"Many patients need massage and manual therapy. So often we think the elderly are too fragile and we neglect to use certain therapies as much as we do in younger patients but that's a big mistake," said Howard Makofsky, PT, DHSc, OCS, associate professor of physical therapy at New York Institute of Technology in New York City. "They need to be touched therapeutically, but that may involve adapting a technique so the patient is more comfortable. For instance, with massage, many elderly have difficulty getting into the prone position, so we may have to adjust the position to a sidelying, sitting or supine position with their legs supported."
"Manual therapy for geriatrics is not only beneficial, but a necessity," agreed Mike S. Rantissi Jr, PT, DPT, MOT, MTC, of the Advanced Manual Therapy Institute in Las Vegas, NV. "With the soft tissue dysfunction and hypomobilities that are present, exercise alone will not address all the impairments. You might make a patient feel a little better, but all dysfunction will return if you manually do not address the structural fault or the muscle impairments."
The demand now is greater than ever as you have a babyboom generation reaching geriatric status and suffering from ailments related to an active lifestyle.
"This population is a very demanding, assertive, pragmatic group of consumers that are now having good cardiovascular function, but are having mobility issues," said Robert E. DuVall, PT, DHSc, MMSc, ATC, OCS, SCS, FAAOMPT, CSCS, manual therapy fellowship director at SportsMedicine of Atlanta (GA), Inc. "The physical therapist is suited to be the best practitioner to meet these needs which really address quality of life. And many of the issues we're seeing are lumbar extension movements that have pathoanatomic symptoms of degenerative disc disease that also result in lower extremity lower back pain - this can be treated with manual therapy."
Screening and Assessment
While massage is typically a prepatory treatment for further physical therapy interventions, it is recommended to help the patient relax, improve blood flow and reduce pain before manipulation and exercise. Many therapists will contest that almost every patient problem has a need for manual therapy, however these techniques are often used on geriatric patients with arthritic conditions, frozen shoulders, spinal stenosis, chronic neck pain, chronic lower back pain, hip pain due to degenerative joint diseases or poor posture related to osteoporosis or Parkinson's disease.
"There are so many applications. In general, manual therapy often helps improve the effectiveness of exercise. Patients who are scared to exercise for fear of hurting, can often exercise in a more pain-free manner following manual therapy," explained Luke Bongiorno, PT, MCMT, a therapist at NY SportsMed & Physical Therapy in New York City. "Often the elderly patients have given up hope; they think they can't do anything. Incorporating manual therapy into their physical therapy allows them to be more comfortable and to get back to the active lifestyle they might have been avoiding. It really gives them their life back."
Laying hands on a person to perform massage therapy does offer a unique psychological benefit. Massage is often associated with positive, stress-free living, which can provide an attractive contrast to a more depressing, less-active elderly lifestyle. Dr. Makofsky found this to be true when he utilized massage and manual therapy for an 89-year-old woman.
"I saw her post total hip replacement in her home. When I got there she was using a walker and looked quite elderly," he remembered. "I found out she was a professional dancer when she was younger and had a dance studio in her basement that hadn't been used in 20 years."
He took her down to the studio and started doing some massage and stretching, and before he knew it, the dancer had returned.
"She was no longer 89, you could see the flexibility return, along with a smile and optimism," he said.
Manual therapy in conjunction with physical therapy can also assist in another mental capacity: posture awareness, something many older adults lack.
"Poor posture awareness seems to be a constant observation in this population. Some resulting signs you will find is severe muscle imbalances and joint hypomobilities," Rantissi said. "Both of these impairments need to be addressed with manual therapy to facilitate a rapid and full recovery. If your goal is to stretch a muscle, but the joint capsule is restricting motion, then a manipulation/mobilization to the joint needs to be administered. By the same token, a patient with tight muscles will begin to develop joint hypomobilities secondary to the decrease arthrokinamatic motion in the joint. Exercise alone will not address these issues. Hands-on techniques, breaking up of adhesions, and mobilizing tissue and joint is what is going to bring that patient to 100% and back to you next time they need a therapist."
Before jumping right in and offering massage to your next geriatric patient, be sure to consider the preexisting factors associated with aging. It's best to take into findings of postural alignment, joint hypomobility, neuromuscular control, muscle length and strength, along with degenerative conditions like osteoporosis, spinal stenosis or osteoarthritis of the hip.
"There's also a need to assess tissue reactivity, which is the sensitivity of the tissues. Some patients are very sensitive and we need to be very gentle in our approach," Dr. Makofsky said. "Other patients are tight and stiff and don't have much sensitivity so we can be more aggressive with them. Being aware of osteoporosis with postmenopausal women is important as well, we don't want to fracture a rib or vertebra."
Every linician should be well aware of the signs and symptoms that may contradict the use of manual therapy - contraindications such as skin lesions, inflammatory processes, neurological deterioration, undertlying fracture, neoplasm, rheumatoid collagen necrosis, cauda equina syndrome, malignancy, systemic disease and blood clotting disorder.
Many therapists try to be a little more gentle than usual during the first session to get a feel for that specific patient's tissue. Keep in mind you are dealing with years of inactivity or many years of repetitive motions.
"A you are performing manual techniques, you should feel the tissue having less spasms or tightness. And if spasm and pain is increasing, you should stop the technique," Bongiorno said. "Also take care if they are acutely inflamed - for instance, constant pain, pain at rest or pain at night. While manual work may feel good temporarily, it may increase their pain afterward."
He also recommends checking to see if patients are on Cumadin or blood thinners, as they may bruise more easily.
Reactions
Massage can relieve muscle tension, inflammation, spasms, fluid retention, aches, stiffness, and pain, however many people are still hesitant to embrace it. Older patients may be more intuitive, asking more questions and needing more of an explanation of what you are doing and why you are doing it. Respect and communication are very important to this population, especially if it is a patient who has not had much human contact in the past.
"Older patients sometimes have more reservations than the younger generations in regards to massage/soft tissue mobilization. In their generation, disrobing in public places and being physically touched by another human being was unaccepted," Rantissi said. "In recent years, health and education has improved and people are seeing the benefits of massage/soft tissue mobilization to maintain a healthy body. Still, we have to remember to talk to them, not at them. This person has lived their life and seen everything most of us have seen three times over. And everyone's feeling about massage is different no matter what the age is. I have even met some physical therapists who think it is gross to touch someone else!"
The key with patients of all ages is making them comfortable before you begin treatment. Explanations of the benefits always helps, including how it improves blood and lymph circulation, range of motion, general flexibility, and increases tissue elasticity (such as with scar tissue). Bongiorno has also seen massage reduce trigger point activity (knots) in muscles, allowing them to work at a better length tension relationship.
"Muscles work best at a certain length, and what can happen in elderly patients especially, is they adopt long sustained postures, so some muscles become short, thus reducing their effectiveness," he said. "Manual techniques also can be powerful to mentally help patients feel they are being treated 'properly' with one on one attention, rather than being left to their own devices."
Reminding patients of the affect massage has on stress levels often helps increase enthusiasm for the technique. However, tapering that strategy depending on the patients situation, and taking into account how their body is aging, is important.
"Manual therapy, comes in many flavors; ranging from light massage to aggressive spinal manipulation or stretching, including all variations in between," Cook said. "It all depends on the patient. In most cases they're as open to this and as appreciative of it as anybody is. I've been a clinician for 18 years, and I've used manual therapy on elderly clients since day one. They respond well, they appreciate you moving an area that's stiff or working an area that's injured."
Sarah Lebo is a freelance writer based in Royersford, PA.
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