4th May. 4 hours. (2 clients)
My first client was a 61-year-old male suffering from pain in both knees, which often woke him up at night, especially when he lay on his side and one knee rubbed against the other. Through passive/active ROM assessment, he described how he was diagnosed with mild arthritis in both knees, elbows, and hands, and to combat such liked to try and keep fit by walking 20km per week and once or twice a week some resistance training with light weights, and during these he did not feel any, or only slight pain once warmed up. He advised he was physically active running marathons up until he was 45-years old but could no longer run through knee pain and constant muscle tears in legs. During active ROM, I got the client to slowly bend his knees (using chair support), which caused pain in both knees, and through palpation he advised there was pain when I pressed along the joint line on the inside of his knees. McMurray (Goossens et al., 2015) test and Apley’s test (Yan et al., 2011) indicated the possibility of a medial meniscus tears, however, given the clients age, history, arthritis diagnosis, and current activity levels, I believed it was more likely cumulative injuries caused through wear and tear and his degenerative arthritis. I advised him to visit his GP and suggested an MRI scan, may identify if he had meniscus damage, perhaps caused through his degenerative arthritis (Xu et al., 2021).
During the assessment I was very aware, the client wished to continue keeping fit, was keen to do so, but upset he could not train at the levels he would like to. I did not wish to dampen his enthusiasm, but if my diagnosis were correct, realistically, he would have to ‘tone down’ his activity levels, hence I remained positive, and suggested some alternative exercises/sports (cycling/swimming), which may assist him to keep fit minus impacting directly on his knees whilst still allowing him to train at the levels he wished. I believe the client appreciated hearing he would be able to continue training. I conducted mobility exercises (flexion-extension); heel slides with resistance bands and strengthening exercises (isometric hamstring contractions), static squat contractions, calf raises, hip abduction, bridges, half squats, and balance board. I also demonstrated some plyometric exercises (Arhos et al., 2021) and agility drills, for him to work on. If I could do anything differently, I would have got him to use the static bike to see if he felt any discomfort in knees, as this may have provided more substance to our discussion, but regardless, I felt the session went very well, and I certainly learned a lot about mindset through speaking and listening to an older athlete.
My final client today was online. An 82-year-old female who had slipped and fell whilst walking 3-days previously, bumping her head, and damaging her hand and fingers in the fall (Fig 1). Her daughter was on the call assisting. She had attended Derriford A&E and no broken bones or concussion had occurred, but she had a badly bruised hand and arm with some stiffness in her right wrist from extending her arm to try and halt her fall. I conducted a passive ROM assessment noting she had no obvious swelling, but some restricted mobility in her hand/fingers, which was likely a grade 1 sprain, hence post advising to conduct PRICE every 2-hours using crushed ice bag or frozen vegetable bag covered with a cloth until they had purchased a proper ice pad, I advised her we would do some gentle exercises, but not to do anything that caused her pain. I wished to increase her range of motion into pronation and supination, hence some gentle wrist flexor stretching was demonstrated, followed by her daughter assisting her to stretch and strengthen her supinator, biceps and brachioradialis muscles. I also demonstrated some hand exercises using play putty and some strong rubber elastic bands, which she liked, and advised purchasing a light resistance band (Fig 2 & 3), as (Di Lorito et al., 2021) recommended.
Fig 1. Bruised hand and arm
Fig. 2: Resistance Band grades
Fig 3: Example – Resistance Band Poundage (different manufactures may differ)
I was very aware and slightly concerned the lady may overdo these exercises, hence constantly emphasised to her daughter and her that she must take her time in her recovery to prevent further injuring herself. In my limited experience of treating the elderly, I have learned that individuals and family groups supporting do not need superficial reassurance and that this could be perceived as patronising. I have become acutely aware some patients respond better to open and frank discussions; particularly elder patients, whilst some hang onto your every word and have real trust in your professional advice and abilities, hence this makes me even more determined to ensure I really make it safe for them and achievable, particularly if they are on limited budgets. It is often more helpful to acknowledge their emotional distress and fears and reassure them that their response, whatever it is, is normal and expected. If I show that I can cope with their distress I can assist them to get the support, they need and this will be critical in getting the best outcome for clients like this elderly patient.
References
Arhos, E. K., Capin, J. J., Buchanan, T. S., & Snyder-Mackler, L. (2021). Quadriceps
Strength Symmetry Does Not Modify Gait Mechanics after ACL Reconstruction, Rehabilitation, and Return-to-Sport Training. The American journal of sports medicine, 49(2), 417.
Di Lorito, C., Long, A., Byrne, A., Harwood, R. H., Gladman, J. R., Schneider, S., …& van der Wardt, V. (2021). Exercise interventions for older adults: A systematic review of meta-analyses. Journal of sport and health science, 10(1), 29-47.
Goossens, P., Keijsers, E., Van Geenen, R. J., Zijta, A., Van den Broek, M.,
Verhagen, A. P., & Scholten-Peeters, G. G. (2015). Validity of the Thessaly test in evaluating meniscal tears compared with arthroscopy: a diagnostic accuracy study. journal of orthopaedic & sports physical therapy, 45(1), 18-24.
Xu, D., van der Voet, J., Hansson, N. M., Klein, S., Oei, E. H., Wagner, F., … &
Runhaar, J. (2021). Association between meniscal volume and development of knee osteoarthritis. Rheumatology, 60(3), 1392-1399.
Yan, R., Wang, H., Ji, Z. H., & Guo, Y. M. (2011). Predicted probability of meniscustears: comparing history and physical examination with MRI. Swiss medical weekly, 141(4950).