#PTonICE Daily Show – Wednesday, April 3rd, 2024 – Group fitness with acute arthritis

In today’s episode of the PT on ICE Daily Show, join Modern Management of the Older Adult lead faculty Jeff Musgrave as he discusses three key steps to keeping older adults moving while injured: symptoms, guardrails, and modifications.

Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog.

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Welcome to the PT on Ice Daily Show. My name is Dr. Jeff Musgrave, Doctor of Physical Therapy. It is Wednesday, so it is all things geriatrics. Happy to be here with you for a PT on Ice Daily Show brought to you by the Institute of Clinical Excellence. So, team, I had a really interesting scenario. One of the things that I do is I’m an owner and a coach in Stronger Life and it’s fitness for people 55 and up. We had a member who had missed a couple weeks trying to go through the diagnostic process for some reactive arthritis. And actually, still, that’s just a working diagnosis. About four weeks now, currently, since diagnosis. But after a couple weeks, she reached out and was like, hey, I really want to get back in the gym. It’s good for me physically. It’s good for me mentally. This is a member that’s been with us for about four years, very dedicated to her fitness, showing up, doing what she can. Each day has gotten really strong and didn’t want to lose her fitness. So here she is in the medical system advocating for herself Which is sad that during this process, you know this this PT first Idea that we’re trying this mission that we’d like to see come to fruition if we’re not there yet. Okay, so she’s had her blood work, she’s had x-rays, all these things are done, she’s getting no intervention, no formal PT, and she’s begging, can I go back to the gym? And we’re like, absolutely. Now, are her providers and her medical team on board with this? Not quite, but that’s okay, because we’re going to take good care of her. So, oftentimes we find ourselves on the other end of this scenario, right, where we are trying to figure out If we’ve got someone we’re treating for some type of injury, an older adult, and they are going to group fitness, how can we set them up for success?

Particularly, we know when we’re working with older adults, it’s all about this game of building reserve and maintaining resiliency. We know we want our older adults to be as strong as possible. We want to put as much distance between minimal ability to function on a daily level and their fitness. We want to build as much margin, build as much reserve as possible, so when illness or injury comes knocking, because we know it’s going to happen eventually, right? We want them to be able to fight back. I want to outline a few things that we do at Stronger Life that I think are just a good guideline if you’re a treating physician and you want your patient to be able to go into group fitness. A lot of these things you’re probably already doing, but just thinking through this lens, we know that the game is vital. We’ve got to keep people moving. We’re trying to get people as fit as possible and keep them that way as long as possible. So I’m going to say, by and large, we believe keeping people moving is paramount. That is what we have to do. We have got to get and keep people moving despite their injuries. With our formal physical or occupational therapy interventions and or in the gym, fitness, Most of the time we can keep them moving if we can set them up for success. So I’ve got three steps that I think will be very beneficial. The same thing that I used for this Stronger Life member, and that is symptoms, guardrails, modifications. Symptoms, guardrails, modifications.

I’m going to set the stage just a little bit more for this patient. So when we’re thinking about this specific scenario, it was reactive arthritis in the knee as a working diagnosis. This member had been nearly non-weight bearing to partial weight bearing limited range of motion, painful loading of the knee. So focused on the knee here. And at this point, two weeks of symptoms, no better. We wanted to dig into her symptoms. So she gave us a heads up she was gonna be coming in, which is nice, we don’t always get that on the fitness side of things, but you’re gonna have that information as a treating clinician. So things we want to know, obviously just like during the diagnostic process, if we’re thinking about what do we need to know about their symptoms going into some type of movement practice or group fitness, or maybe group fitness are already engaged in. We wanna know their ags. We wanna know what’s making these symptoms worse. Is it the range of motion? Is it the pain? Is it the volume, the number of repetitions? Is it power-based movements that are exacerbating their symptoms? And this is all information you’re gonna know about your patient that you’re treating already. So we wanna know that. and set those baselines. So if you’re treating the patient, you probably already know the symptoms. Step one, check. We know for this specific case scenario, it was painful range of motion past about 30 degrees. 30 degrees of knee flexion is about all we could get. Weight bearing Sometimes not exacerbating symptoms, sometimes it was. So the member was walking in on a cane and was very leery of weight bearing. So the things I knew about this member coming in is they’ve had chronic knee pain for a long time. Their baseline, she’s telling me, is a five out of 10. It was a nine out of 10. She was in the ER on pain medication. Two weeks later, she’s weight-bearing, ass-tolerated, on a cane, about 30 degrees of knee flexion. Loading the joint through range is painful, okay? So that’s kind of the information I knew coming in. Dug in just a little bit right before class.

And then we need to set some guardrails. So now that we know the ags, we also want to know the irritability. How irritable are these symptoms? If we flare this up, is she going to go into non-weight-bearing status? And is this going to affect her activities of daily living the rest of the day? or is she going to have a little increase and then as she rests symptoms are going to come back down. It wasn’t, her symptoms in this scenario were not like once they’re spurred on she’s dealing with these for days. So I put her in the low irritability category. Symptoms had been severe but they have been stable. So I wasn’t really too worried about her Causing any symptoms in class but wanted to have some some options to take her out of weight-bearing make sure we’re limiting her range of motion because we had identified those were the things that were exacerbating her symptoms, so That was the symptom baseline irritability, I would say low and then some guardrails and So for her, we let her push into the discomfort and set some guardrails. Hey, if your pain gets five out of 10s your baseline, if you hit a seven out of 10 or above, we need to make some changes. You need to pull me over, we’ll cut the range of motion, or we can reduce weight bearing.

And then the last thing that we need to do is we need to give her some modifications. So we knew it was range of motion, and weight-bearing positions. So those are the two things we’re looking at first. So I’m going to give you the exact workout we did and then we’ll walk through symptoms, guardrails, modifications, and how we went through this. So the workout was a station-based workout where it started with weighted step ups. Okay, you can see how that could be a problem. Then we had sumo deadlift high pulls, which were weight bearing. We had some time on the rower. We had a three position balance movement. So it was dynamic balance with a water tube. And the last thing was spending some time on the ski. Heard different movements with her to work on modification. So she was weight-bearing with the cane, she was not able to do much more than a few steps, so we knew adding weight wasn’t going to work. So we got to the weighted step-ups, I had her try it just with a couple inches, cut the range of motion, cut the load, still uncomfortable. I took her over for a wall sit, wall sit didn’t work either. Okay, so cut the range of motion, cut the load, still too painful. So what did I end up doing? I ended up replacing the movement. And this is the last thing we want to do, right? We want to stick to the body group to get the desired stimulus from I had misjudged a little bit. She was a little more irritable than I thought, couldn’t tolerate a static position to work the lower extremities, couldn’t handle the reduced range of motion or the reduced load. So instead of replacing it, she ended up doing a seated Russian twist, okay, working on some core work, taking her knees completely out of weight bearing for that movement. Next movement, we got sumo deadlift high pull. Since I knew she couldn’t tolerate much load plus, like body weight plus resistance, I went ahead and put her on a box to do a sumo deadlift. So she’s still, she’s in a seated position, has a dumbbell in each hand. She’s driving from her feet, giving us this nice high pull motion. So she’s still working her legs, her hips, her core. We’re able to maintain the stimulus on that one, which was great. She was able to tolerate that. The next movement was the rower. So on the rower, I knew that her range of motion, she had about 30 degrees. That’s all we could work with. Rower, pretty friendly place for people, especially with reactive knee arthritis. So she can control the range of motion and it’s limited resistance, right? We’ve taken gravity out of the picture here. So what I did is I had her put her feet on the floor of the rower and just drive through her feet and cut the range of motion. And she was able to tolerate that really well and actually saw progress during this workout from the beginning of the workout to the end of the workout with her getting more and more range of motion. She actually said that time on the rower made her knee feel really good. So that was good. So we modified the rower. Then we’ve got this dynamic balance movement where you’re starting on one leg, quick step, and then standing on the other. So there’s a dynamic component, there’s a power piece, there’s a single leg support piece, and we know weight bearing on both legs is okay. Single leg is kind of out of the picture. So we had her work on some weight shifting, holding a little bit of load and she was okay with that, which kind of surprised me. And actually as the workout went on, she ended up doing a little bit of single leg support and weight shifting until she was on one leg and then the other. So that was a replacement. So that dynamic power-based movement ended up being more like weight shifting side to side. I gave her the option to close her eyes to make it a little more challenging and the surface she was on was dynamic. So that was the modification there. When it came to the ski, knowing how much weight bearing was in there, she’s walking from station to station, I had her do the ski from a seated position. So arms length away, the setup is still very similar for the ski, reaching up nice and tall, pulling to the hips. So she’s still getting a cardiovascular stimulus, she’s still working overhead pulling, so we’re able to maintain the stimulus. So that is the process that I went through, looking at her reactive knee arthritis, trying to figure out what she could tolerate, cutting the range of motion, cutting weight bearing, but she got a great workout. Her fitness is better because of it. She’s worked really hard to maintain and build that reserve and resiliency, and we’re able to go through and give her a great modification, something that’s meaningful and helpful, trying to stick with maintaining the stimulus as much as possible, what direction, what muscle groups, and then last case scenario on modification, sometimes we just have to replace it. What’s something valuable you can do, even if it’s not the same muscle group, not the same position? So oftentimes when I’m, I gave you kind of the scenario I did this with for this patient in particular, knowing weight bearing and range of motion was limited and producing symptoms. But when you’re thinking about just in general, oftentimes cutting the range of motion, cutting the load, those two can help. If those don’t help, you can still maintain the stimulus from going from a dynamic, to a static position. So say it was push-ups, for example, are painful, can we do a static plank? Tristatic, so cut the range of motion, cut the load, take them a little bit more out of the weight bearing position, and then tristatic. If you can’t do a static with reduced range of motion, reduced load, then it’s time to start thinking about replacing that with another upper extremity movement. But if you’re in a scenario where you’ve got to make a decision quickly, or you’re trying to arm your patient to make these modifications in a group class, just have them see if there’s anything else they can modify going in. So the reality is this patient is still in the diagnostic process. There has not been any solid diagnosis for her, no clear prognosis, still getting no intervention. She’s been coming to group classes for two weeks. Her pain is better. Symptoms are reduced. Range of motion is improved. She’s walking without the cane all while awaiting her one-on-one intervention and a diagnosis. So during this time she’s been able to improve her fitness, improve her range of motion, improve her weight-bearing tolerance, and the other benefit that she brought up, which we’ve not discussed yet, is just the mental and emotional piece. we have to remember for older adults, maybe they’re seeing us for a pain or a problem, if we can keep them moving in the group setting, we can equip them with the guardrails, we know what causes their symptoms, we know what we need to modify, because we’re already working around them, we just need to give them modifications they can use once they get into the group fitness environment. And she’s getting better, even though she’s had no formal intervention yet, which I love. But the other piece is the social isolation piece. For our patients, a lot of our older adults are socially isolated. That changes our health outcomes, team. Friends save lives. And keeping our older adults connected with their social networks is crucial to treat the whole patient. And she said mentally and physically, she has felt a lot better. And if you’ve done any studies, looked at any of the studies for chronic pain, We know that keeping people moving and some of these mental emotional factors can be huge in the experience of pain. The things we want to do to set our older adults up for success, to keep them moving in the group environment as much as possible, to maintain that reserve, to maintain those social connections, is we’ve got to know their symptoms. We’ve got to know their ags. We’ve got to know what makes their symptoms worse, their symptom irritability. After we know their symptoms, it’s guardrails. If this, then that. If your symptoms get to, in this scenario, was a seven out of 10, then we need to cut the range of motion, cut the load, or we need to take you out of weight bearing. And then the last piece is to be set with those modifications just like we outlined. We knew for this client, the range of motion, the load was the issue. So those are the things that we changed. And if those two things don’t work, then we completely replace it. But the more we can get and keep people moving, The more we can help them maintain their fitness and their social connections, ultimately, the better their outcomes are gonna be in our clinic. So, I hope that was helpful. Real life scenario, patients getting better, no formal PT, symptoms, guardrails, modifications. Team, I hope that was helpful. I would love to hear your thoughts on that. If you have any other strategies you like to use to modify around symptoms, in particular to equip your patients for the group training environment, I would love to hear about those.

If you are interested in coming to check out us for more mmoa content we have got our mmoa level one eight week online course level one is happening may 15th if you’ve already had level one you’re looking for level two it’s going to be may 16th We’ve got our live course is gonna be in Raleigh, North Carolina, Urbana, Illinois. We’re gonna be in Burlington, New Jersey, and we’re gonna be, I’m gonna be in New Orleans, Louisiana this weekend. Team, the live courses are a lot of blast. If you’ve not been to one, you should come check us out. The weekend after, if you’re on the West Coast, I’ll be in Bellingham, Washington. Would love to see y’all in the live course. If you get a chance, love to hear your thoughts on this topic, on this case study, keeping people moving in group fitness despite their injuries and symptoms. Have a great day team. We’ll catch you next time.

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