Joint Distraction Buys Time Against Knee Replacement For Osteoarthritis

PARIS, June 13 -- Mechanical joint distraction for osteoarthritic knees can restore near-normal function and help patients put off joint replacement, perhaps for years, according to a small study reported here.

Among 25 patients followed for two years, a two-month stint with an external fixation brace has provided lasting pain relief and functional improvement and reduced wear-and-tear on knee cartilage, Floris Lafeber, Ph.D., of University Medical Center Utrecht in The Netherlands, reported at the European League against Rheumatism (EULAR) congress.

The same procedure for ankles has reduced pain and restored function for as long as four years, and some patients with osteoarthritis of the hip have been followed for as long as 10 years after joint distraction procedures, Dr. Lafeber said.



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Prevention Of Mobility Problems In Elder Care At Home

From the AGS Foundation For Health In Aging





Understanding the Problem


The changes that occur with aging can lead to problems with mobility (ability to move around), such as unsteadiness while walking, difficulty getting in and out of a chair, or falls. Muscle weakness, joint problems, pain, disease, and neurological (brain and nervous system) difficulties-common conditions in older people-can all contribute to mobility problems. Sometimes several mild problems occur at one time and combine to seriously affect mobility.

The number one mobility problem that older people experience is falls. Falls result in broken bones, bruises, and fear of falling. Older bones break more easily than younger bones and they heal less quickly and not as completely. If a hip is fractured, canes, walkers, or wheelchairs might be needed permanently. Falls are a major cause of injury and death, so prevention is important.

When an older person falls, but does not suffer serious injury, he or she might still have difficulty getting up from the fall. If the person is in serious pain, or has clearly suffered an injury, wait for help to arrive. However, if he or she has not been seriously injured but is having difficulty moving and getting up, he or she may be able to crawl (on hands and knees) to a solid chair and use it as a support in getting up. If the person is lying on his or her back, instruct him or her to first roll onto one side and then into a side-lying position to an all fours (on hands and knees) position. If the person needs your help to get up, lift him or her with your arms by bending your legs, not your back. (Bend at your knees and push up with your legs.) Once the person is in an all fours position, instruct him or her to crawl towards the seat of the chair and lift the trunk of the body up with hands on the chair; he or she should then bring one foot up into half-kneeling position and from there either sit into the chair or stand up. If the person can't do this, you will need to call for help.

An injury from a fall may result in 24-hour-a-day bed rest. Unfortunately, this can worsen existing medical illnesses and lead to new ones such as circulatory problems including blood clots in the legs, further loss of strength, pressure sores, or pneumonia.

When older people have falls-even if the fall isn't serious-they often become fearful of falling again. This can lead to inactivity that can cause additional health problems. One of the most important things you can do to help someone with mobility problems and fear of falling is to encourage physical activity. Even a little activity strengthens bones and muscles, improves steadiness when walking, and helps prevent fractures. If the older person is afraid of falling, suggest using a cane or a walker. Sometimes older people are afraid they will not be able to get up from a fall. It is important to teach how to get up from a fall before the fall occurs. In some cases it can be helpful for the older person to practice getting up from the floor. A physical therapist can help with teaching a person how to do this. In addition to helping the older person stay active, you can help prevent falls and fractures by doing a home safety check and correcting conditions that could lead to falls.

Tell the doctor or nurse about mobility problems of the person you are caring for and especially mention any falls, since they can be caused by medical conditions. Medicines, prescription, non-prescription, herbal or other remedies, alcohol, or worry can result in drowsiness or distraction, which can lead to falls. Certain medical conditions such as poor eyesight and diseases like arthritis can also affect mobility. The risk of falling can often be reduced if the medical condition is diagnosed and treated.


Your goals are to:

  • Prevent falls by reducing hazards in the home

  • Encourage activity/exercise to improve mobility and strength

  • Report any recurrent falls or near falls to the doctor for a medical evaluation


When To Get Professional Help


Call the doctor or nurse immediately or go to the emergency room if any of the following symptoms occur

  • The older person has experienced a major fall.

    When older people experience a hard fall, such as when their legs suddenly move out from under them and they land forcefully on their back, side, or head, it is important that they be evaluated as soon as possible. Call the doctor immediately in this case. Even if the older person does not appear to be injured, make an appointment with your doctor for an evaluation.

  • Loss of consciousness after a fall.

    Possible causes include drugs, a stroke, a heart problem, diabetes, seizures, dehydration, or a head injury during the fall.

  • Complaints of pain after a fall, especially in the hip or in the groin.

    This could mean a fractured hip or pelvis.

  • There are symptoms such as fever, coughing, or difficulty breathing at the time of the fall.

    Falls can sometimes indicate illnesses such as heart disease, pneumonia, or other infection.

Call the doctor or nurse during office hours to discuss the following problems

  • Recurrent falls or tripping for no apparent reason.

    This could indicate Parkinson's disease, dementia, poor eyesight, or medications.

  • Obvious problems with gait and balance (such as a limp or dragging a foot).

    This could be caused by thyroid disease, nerve injury, a stroke, Parkinson's disease, or other problems in the joints, bones, muscles, spinal column, or brain.

  • Decrease in activity level or inability to walk usual distances.

    These could be caused by heart disease or a lung condition such as emphysema or infection, a stroke, depression, circulatory problems, or over-medication with sedatives or tranquillizers. It is important to find the reason for the problem and, where possible, treat it.

  • Recurrent falls or tripping for no apparent reason.

    This could indicate Parkinson's disease, dementia, or poor eyesight, or could be a result of prescribed medicine.

  • Feeling lightheaded or dizzy.

    High blood pressure, depression, diabetes, heart disease, chronic pain, and insomnia are common problems among older people. Many of the drugs used to treat these conditions can make a person lightheaded, dizzy, or less alert, especially at night and can increase the risk of falling and fracturing a bone.

  • If you are unable to help the person get around.

    The doctor may arrange for a physical therapist, social worker, or visiting nurse to show you how to help and, if necessary, arrange for outside assistance or medical equipment such as a wheelchair or walker.

Know the answers to the following questions before calling the doctor:

(A useful acronym for remembering the important parts to a fall history is SPLAT: symptoms, previous falls, location, activity, and time.)

Symptoms

  • Did the person report pain or discomfort?

  • Did the person lose consciousness?

  • What medicines is the person taking?

  • Did the person complain of lightheadedness, dizziness, weakness, chest pain, or palpitations prior to the fall?

  • Does the person have a history of heart disease, high blood pressure, diabetes, stroke, Parkinson's disease, memory loss?

Previous falls

  • Has this person fallen more than once in the last few weeks?

Location

  • Where did the fall occur?

Activity

  • What was the person doing at the time of the fall?

Time

  • What time of day did the fall occur? How long ago?

Here is an example of what you might say when calling for help

"I am Susan Smith, daughter of John Smith. My father fell early this morning at 6:00 a.m. (Time) while getting up from the toilet (Activity) in the bathroom (Location). He fell on his left side on the grab bar but caught himself before he fell to the ground. He became dizzy (Symptoms) and lost his balance when he stood up. I don't think he hurt himself, but he is very shaken up and continues to have dizziness with any quick movements. A similar thing happened when I was helping him out of bed earlier this week (Previous falls), but I was there to catch him before he lost his balance. Should I bring him to see you?"


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What You Can Do To Help


Identify fall hazards in the home and eliminate them.

Many older people fall because of unsafe conditions at home. Use the Safety Check List (adapted from the National Safety Council) reprinted at the end of this chapter to help make sure the older person's environment is as safe as possible.

Pay special attention to safety proofing the bathroom since this is where most falls occur. Put rubber appliqués or rubber mats on the tub bottom. Tubs and showers are easier to get into if side rails are added or if handrails are installed onto shower walls. Toilet seats can be raised and side rails attached to the toilet. These safety items can be purchased at medical equipment stores or through their catalogs. In addition, special toilets that have a higher seat than standard ones can be installed by a plumber.

Ask the nurse or therapist for help.

Visiting nurses, occupational therapists, or physical therapists that come to the home can identify fall hazards and make recommendations to improve safety. They can help you conduct your own home safety check or do one for you.

Help the older person stay physically active.

A regular program of exercise can strengthen muscles and improve flexibility. With increased strength and balance, an older person is better able to maneuver and avoid a potential fall. Some simple exercises that older people can do are included at the end of this chapter. Ask the doctor if these exercises would be beneficial for the person you are caring for.

Check with local hospitals, senior centers, and community centers to see if they offer fall prevention, exercise, or walking programs for older people

Ask the doctor about walking aids.

A large selection of canes and walkers is available that make mobility easier and safer. Older people who use a cane should be encouraged to carry it with them at all times. If they are even a little bit unsteady on their feet, they should use a cane or walker. Some of the newer designs of walkers even come with a built-in seat, which allows the person to sit and rest when tired. Although canes and walkers can be purchased at some drug stores, it is a good idea to check with a doctor or physical therapist to find out what type of cane or walker the older person needs. A physical therapist will make sure the cane or walker is adjusted to the right height and teach the older person how to use it.

Ask the doctor to check all medicines being taken-prescription, non-prescription, herbal, and other remedies

Throw out all outdated medicines and, with the doctor's assistance, stop similarly acting medicines and make the medicine plan as simple as possible.

Make sure vision and hearing are tested regularly and properly corrected.

Seeing poorly or not hearing well can be a cause of mobility problems and can lead to falls. Make sure the older person is especially careful just after getting new bifocal or tri-focal eyeglasses. If the ground is out of focus on looking down through unfamiliar lenses, the likelihood of falling is increased.

Make sure proper footwear is worn.

Sturdy, well-fitted, low-heeled shoes with wide, nonstop (rubber soles) should be worn. A walking shoe with good arch support and heel counter is recommended. Avoid slippers (unless they have non-slip soles), clogs, or sandals that can easily come off. Avoid long shoe laces, or pants that are too long which can cause tripping.

If the older person is afraid of falling, discuss these fears.

People with a fear of falling will need to practice doing the things of which they are afraid. Otherwise, they will not get the exercise they need and this can lead to other medical conditions such as circulatory problems. Set small goals and gradually build up the activity level. Start by doing activities while someone is present to help and give support. Build confidence by giving praise and encouragement, then gradually encourage being active when alone.

Create opportunities for socializing.

Look for community activities that will keep the older person mobile. (See "mallwalking" below.)

Don't help the older person too much.

Resist the temptation to do everything for the older person because you are afraid "something might happen." Older people need to stay active and like to remain independent.


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Carrying Out and Adjusting Your Plan


Problems You Might Have Carrying Out Your Plan

Problem:
"I don't need to do special exercises. I get enough exercise just from walking."

Response:

Walking is good exercise, but the doctor or physical therapist can also prescribe special exercises to prevent problems that can lead to falls. For example, a physical therapist might recommend special posture exercises that will strengthen and improve balance. A physical therapist can sometimes identify the underlying cause for balance and mobility problems and recommend specific balance-improving exercises that will reduce the risk for falling. Unless specific exercises are performed to address such problems, the problems will continue.

Problem:
"It's normal for older people to have decreased mobility."

Response:

Significant loss of mobility is not part of normal aging. In the healthy older person it has more to do with inactivity. With regular exercise, strength and flexibility can be preserved for a longer time.

Problem:
"I'm afraid she will fall again."

Response:

A certain amount of fear and respect for hazards is healthy, but too much ends up restricting mobility, which makes the likelihood of falling greater. To overcome this obstacle, be creative. For example, it might be easier for the older person to overcome the fear of falling by simply being with other people. Help the older person find a friend to walk with or an exercise program to join. Investigate "mall walking" if the climate is very hot in summer or cold in winter. In many places groups of seniors meet daily and walk the mall. Some shopping malls even open an hour or so early to encourage this activity. Many social contacts are made when this occurs.

Problem:
"I don't need a walker."

Response:

Walkers can prevent falls by making mobility easier and safer. Using a walker allows the older person to continue to walk independently and not be confined to a wheelchair or admitted to a nursing home. Say to the person, "Isn't it worth it to use a walker?"

Problem:
"I can't afford to install the recommended safety device."

Response:

Most safety changes are easy to make and are not expensive. There are volunteer organizations that can help you buy and install safety equipment. If money is a problem, ask to talk to a social worker who will advise you about financial help that may be available.

Think of Other Problems You Might Have Carrying Out Your Plan

What other problems could get in the way of doing the things suggested in this chapter? For example, will the older person cooperate? Will other people help? How will you explain your needs to other people? Do you have the time and energy to carry out this plan?

You need to make plans for solving these problems. Use the four COPE problem-solving steps in the chapter on "How to Use the Eldercare at Home Book to Solve Caregiving Problems."


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Checking on Progress


Be realistic about expecting change. A large part of your plan will be prevention. Don't be discouraged if you do not see an increased level of activity. If the older person is maintaining activity and no falls are occurring, your plan is working because you are preventing the problem from getting worse.

What to Do If Your Plan Isn't Working

If mobility problems are getting worse, ask the doctor or nurse for help. Tell them what you have done and what the results have been.

- Laurence Z. Rubenstein, MD, MPH
- Richard W. Sattin, MD, FACP

- Peggy R. Trueblood, PhD, PT



A Few Words About Wheelchairs


If the older person cannot get around by foot anymore and must use a wheelchair, exercises are still very important to keep bones strong and joints flexible. The old saying still holds true: "If you don't use it, you lose it." Not all older people need to use wheelchairs full time. It can be a good idea to use a wheelchair for long distances in order to save time and to avoid fatigue. Depending on the needs of the person who will use the wheelchair, the doctor or physical therapist will be able to make suggestions for the type of wheelchair to use, what features it should have, and how to use it safely.

Managing the person in a wheelchair

The wheelchair should be a good fit

  • A wheelchair that is too wide can cause bad posture.

  • A too narrow wheelchair can cause skin breakdown from rubbing against the frame of the chair.

  • At the most, the person should have one-inch clearance on each side of the chair.

  • When sitting in the chair, weight should be equally distributed and the trunk and limbs should be balanced.

  • Two to three inches between the front of the seat and the knee joint helps proper weight distribution and prevents cutting off circulation to the legs, or pressing on nerves to the legs and feet.

  • Leg rests should clear the floor by two inches.

  • The chair size should change if there is significant weight loss or gain.

  • If the older person will be in the chair most of the day, consider getting good cushions.

  • Older people can develop tendon and joint contractures when they are in a wheelchair for long periods of time. This can mean the muscles do not stretch, and can become weak. To avoid this, he or she should lie on the stomach or back with legs and back fully extended for periods of time each day. Gentle stretching exercises while in this position are helpful.

Consider where the chair will be used?

  • If you live in a mobile home, you may need a narrower framed chair.

  • A lightweight chair is easier to take in and out of a car and is best for a person who travels often.

  • Wheelchairs can be customized and there are many accessories available. Armrests can be made to fit under a desk, leg rests can be detachable or swing away, and lap boards and trays can be used for meals.

  • There are two types of wheels for wheelchairs: pneumatic and solid. Pneumatic wheels give a better ride and may be necessary for a very frail older person. This type of wheel requires maintenance. The solid wheels are fine if the chair is being used only in the home and not for travel. The maintenance for this wheel type is very low.

Safety Precautions

  • Seat belts should be worn whenever the wheelchair is in motion.

  • Keep the chair in good working order. Check the brakes, air in tires, and upholstery. Oil the metal joints to insure that they work smoothly and to prevent rust.

  • When assisting someone in a wheelchair up or down a curb, first tilt the chair back on its large back wheels. Then, while balancing the chair on the large wheels, slowly lower the chair down over a curb. When going up a curb, turn the chair around (backwards) so the person in the chair is facing away from the curb. Again, slightly tilt the chair back on its large back wheels. Pull the chair up over the curb while balancing the chair on the back wheels.

  • When putting a wheelchair into the trunk or back seat of a car or van, remove any parts that are detachable such as the cushions and leg rests. Then, fold the chair and place it on its side in the trunk, or upright if you are putting it in the back seat of a car or van. Remember to bend your legs, not your back when lifting any heavy object.




Exercises for Persons 55 Years Old and Older


These exercises are to be started gradually. Work at your own pace and level of ability. Start with five or ten repetitions; do fewer if necessary or more if you can. Slowly increase by adding two to four or more repetitions every five to ten days. Progress until you can do approximately 15 to 25 repetitions of each exercise. Do these exercises daily if possible, but at least three times weekly.

  • High step

    Purpose: To increase hip and leg strength and balance

    Hold on to a chair for balance; stand up straight. Raise one foot off the floor so that your knee is as high as your hip. Reverse legs. Try not to lean on the chair too much. As you get stronger, you may be able to raise your leg higher, hold for count of 5 (less if necessary), and decrease amount of leaning on chair.

  • Side step

    Purpose: To increase hip and leg strength and balance

    Hold on to chair for balance; stand up straight. Move one leg out to your side and hold it in the air. Don't bend at the waist. Hold leg for 5 seconds (or less if necessary). Reverse legs. At first, you may be unable to hold your leg in the air. If so, simply move your foot out to the side.

  • Stand up -- sit down

    Purpose: To improve strength, balance, coordination, and joint motion

    This is the key to being independent. Simply stand up, then sit down. To do this, you must get your feet under the front of the chair. Move your center of gravity forward and then up. If necessary, use the chair's armrest. As you get stronger, decrease the amount of push that you need from your arms.

  • Shoulder shrug

    Purpose: To strengthen back, stretch chest muscles, and improve posture

    Sit up or stand up straight. Shrug your shoulders up high and release. Pull your shoulders back. You should feel your shoulder blades pull together.

  • Cervical range of motion

    Purpose: To improve posture, balance, and range of motion

    Sit up or stand up, head erect but not forward.
    Turn your chin to your left shoulder and reverse to the right.
    Lean your ear to your left shoulder and reverse to the right.
    Lightly place your finger on your chin and push your chin backward. Do not roll your head backward as if looking up at the ceiling.

  • Toe, heel, and leg rises

    Purpose: To improve ankle strength for balance

    While holding on to the back of a chair or countertop, stand straight and tall, with your knees slightly bent and your toes pointed straight ahead. Line your knees up over the point of your shoes. Look straight ahead. Keep your chin tucked and your shoulder blades back. Tighten your stomach muscles.

    First, rise up on your toes and then lower yourself down.

    Second, raise the toes and front part of your feet while shifting weight to the heel.

    Third, lift one leg and hold for 10-30 seconds.

    Lower and repeat with other side.

    Slowly and carefully repeat each exercise 3-5 times.

  • Eyes- Closed balance exercises

    Purpose: To improve balance

    Focus your eyes on a target 10-20 feet away while you change from sitting to standing and back again with your eyes OPEN. Make sure that you land softly when you sit. Repeat with your eyes CLOSED.

    As you do this exercise, feel the position of your body as you move. Be sure that you keep your weight forward on the front of your feet, knees apart, chest forward, and spine erect.

  • Half- Circle sway

    Purpose: To improve balance

    If you have experienced falls or problems with balance, get permission from a physical therapist before doing this exercise.

    Stand with your feet shoulder distance apart. Hold onto a counter or sturdy table for safety. Lean forward slowly from the ankles without bending the hips so that 70% of your body weight is on the balls of your feet.

    Return to neutral standing position.

    Lean slowly to the left until 70% of your weight is on the left side of your feet.

    Return to neutral standing position.

    Lean slowly to the right until 70% of your weight is on the right side of your fee.

    Return to neutral standing position.

    Now put it all together making graceful half- Circle sways from left to center to right and back again.

  • Walk, walk, walk

    Purpose: To enhance overall health of muscles, bones, joints, circulation, heart, lungs, digestion, bowels, and mind.

    Walk at whatever level of ability you have. If you can walk only 50 feet, start at that level and try to increase the distance and improve your gait speed. Avoid stops and starts. If you are walking longer distances, such as a half-mile in 5 to 10 minutes, do a little stretching before starting. When finishing your walk, cool down by walking slowly, stretching, and doing a few of these exercises or your favorite ones.

  • If you need help getting started or if you have any concerns about your health, show these exercises to your physician.

    Adapted from Border B and Wagner M. Functional Performance in Older Adults. FA Davis, Philadelphia, PA:1994, pp. 60-61 and "What You Need To Know About Balance and Falls. A Physical Therapist's Perspective," American Physical Therapy Association, Alexandria, VA: 1998.


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