Geriatric rehabilitation and resilience from a cultural perspective.

Resiliency is a key aspect to aging successfully. Promoting healthy lifestyles, strong social bonds, enhancements to one's environment, accessibility to quality care and rehabilitation are critical in a positive aging experience. Issues of personal, social, medical, and rehabilitative care are addressed in the context of resiliency from a cultural perspective. Various research studies explore resiliency through the progression of aging within changing environments, medical needs, and social conditions. Findings suggest that a strong connection to culture, accessibility to medical attention, and comprehensive assessment of a patient's background can effectively improve the rehabilitation for an aging individual. This article addresses aspects of caregiving that are essential in raising cultural sensitivity and resiliency, discussing three case studies (i.e. fall risk; stroke; congestive heart failure) in the geriatric patient. Resiliency in culture and rehabilitation has a connection needed to advance the quality of care and quality of life for an aging patient population.

The pattern of tibial nerve excursion with active ankle dorsiflexion is different in older people with diabetes mellitus.

BACKGROUND: The peripheral nervous system has an inherent capability to tolerate the gliding (excursion), stretching (increased strain), and compression associated with limb motions necessary for functional activities. The biomechanical properties during joint movements are well studied but the influence of other factors such as limb pre-positioning, age and the effects of diabetes mellitus are not well established for the lower extremity. The purposes of this pilot study were to compare the impact of two different hip positions on lower extremity nerve biomechanics during an active ankle dorsiflexion motion in healthy individuals and to determine whether nerve biomechanics are altered in older individuals with diabetes mellitus. METHODS: Ultrasound imaging was used to quantify longitudinal motion of the tibial nerve and transverse plane motion of the tibial and common fibular nerves in the popliteal fossa during active ankle movements. FINDINGS: In healthy individuals, ankle dorsiflexion created mean tibial nerve movement of 2.18 mm distally, 1.36 mm medially and 3.98 mm superficially. When the hip was in a flexed position there was a mean three-fold reduction in distal movement. In people with diabetes mellitus there was significantly less distal movement of the tibial nerve in the neutral hip position and less superficial movement of the nerve in both hip positions compared to healthy individuals. INTERPRETATION: We have documented reductions in tibial nerve excursion due to limb pre-positioning thought to pre-load the nervous system using a non-invasive methodology. Thus, lower limb pre-positioning impacts nerve biomechanics during ankle motions common in functional activities. Additionally, our findings indicate that nerve biomechanics have the potential to be altered in older individuals with diabetes mellitus compared to younger healthy individuals.

Mechanosensitivity during lower extremity neurodynamic testing is diminished in individuals with Type 2 Diabetes Mellitus and peripheral neuropathy: a cross sectional study.

BACKGROUND: Type 2 Diabetes Mellitus (T2DM) and diabetic symmetrical polyneuropathy (DSP) impact multiple modalities of sensation including light touch, temperature, position sense and vibration perception. No study to date has examined the mechanosensitivity of peripheral nerves during limb movement in this population. The objective was to determine the unique effects T2DM and DSP have on nerve mechanosensitivity in the lower extremity. METHODS: This cross-sectional study included 43 people with T2DM. Straight leg raise neurodynamic tests were performed with ankle plantar flexion (PF/SLR) and dorsiflexion (DF/SLR). Hip flexion range of motion (ROM), lower extremity muscle activity and symptom profile, intensity and location were measured at rest, first onset of symptoms (P1) and maximally tolerated symptoms (P2). RESULTS: The addition of ankle dorsiflexion during SLR testing reduced the hip flexion ROM by 4.3° ± 6.5° at P1 and by 5.4° ± 4.9° at P2. Individuals in the T2DM group with signs of severe DSP (n = 9) had no difference in hip flexion ROM between PF/SLR and DF/SLR at P1 (1.4° ± 4.2°; paired t-test p = 0.34) or P2 (0.9° ± 2.5°; paired t-test p = 0.31). Movement induced muscle activity was absent during SLR with the exception of the tibialis anterior during DF/SLR testing. Increases in symptom intensity during SLR testing were similar for both PF/SLR and DF/SLR. The addition of ankle dorsiflexion induced more frequent posterior leg symptoms when taken to P2. CONCLUSIONS: Consistent with previous recommendations in the literature, P1 is an appropriate test end point for SLR neurodynamic testing in people with T2DM. However, our findings suggest that people with T2DM and severe DSP have limited responses to SLR neurodynamic testing, and thus may be at risk for harm from nerve overstretch and the information gathered will be of limited clinical value.

Age-related hyperkyphosis: its causes, consequences, and management.

SYNOPSIS: Age-related hyperkyphosis is an exaggerated anterior curvature in the thoracic spine that occurs commonly with advanced age. This condition is associated with low bone mass, vertebral compression fractures, and degenerative disc disease, and contributes to difficulty performing activities of daily living and decline in physical performance. While there are effective treatments, currently there are no public health approaches to prevent hyperkyphosis among older adults. Our objective is to review the prevalence and natural history of hyperkyphosis, associated health implications, measurement tools, and treatments to prevent this debilitating condition. LEVEL OF EVIDENCE: Diagnosis/prognosis/therapy, level 5.J Orthop Sports Phys Ther 2010;40(6):352-360, Epub 15 April 2010. doi:10.2519/jospt.2010.3099.

Upper extremity impairments in women with or without lymphedema following breast cancer treatment.

INTRODUCTION: Breast-cancer-related lymphedema affects approximately 25% of breast cancer (BC) survivors and may impact use of the upper limb during activity. The purpose of this study is to compare upper extremity (UE) impairment and activity between women with and without lymphedema after BC treatment. METHODS: 144 women post BC treatment completed demographic, symptom, and Disability of Arm-Shoulder-Hand (DASH) questionnaires. Objective measures included Purdue pegboard, finger-tapper, Semmes-Weinstein monofilaments, vibration perception threshold, strength, range of motion (ROM), and volume. RESULTS: Women with lymphedema had more lymph nodes removed (p < .001), more UE symptoms (p < .001), higher BMI (p = .041), and higher DASH scores (greater limitation) (p < .001). For all participants there was less strength (elbow flexion, wrist flexion, grip), less shoulder ROM, and decreased sensation at the medial upper arm (p < .05) in the affected UE. These differences were greater in women with lymphedema, particularly in shoulder abduction ROM (p < .05). Women with lymphedema had bilaterally less elbow flexion strength and shoulder ROM (p < .05). Past diagnosis of lymphedema, grip strength, shoulder abduction ROM, and number of comorbidities contributed to the variance in DASH scores (R (2) of 0.463, p < .001). IMPLICATIONS FOR CANCER SURVIVORS: UE impairments are found in women following treatment for BC. Women with lymphedema have greater UE impairment and limitation in activities than women without. Many of these impairments are amenable to prevention measures or treatment, so early detection by health care providers is essential.

Mechanosensitivity of the lower extremity nervous system during straight-leg raise neurodynamic testing in healthy individuals.

STUDY DESIGN: Cross-sectional, observational study. OBJECTIVES: To explore how ankle position affects lower extremity neurodynamic testing. BACKGROUND: Upper extremity limb movements that increase neural loading create a protective muscle action of the upper trapezius, resulting in shoulder girdle elevation during neurodynamic testing. A similar mechanism has been suggested in the lower extremities. METHODS: Twenty healthy subjects without low back pain participated in this study. Hip flexion angle and surface electromyographic measures were taken and compared at the onset of symptoms (P1) and at the point of maximally tolerated symptoms (P2) during straight-leg raise tests performed with ankle dorsiflexion (DF-SLR) and plantar flexion (PF-SLR). RESULTS: Hip flexion was reduced during DF-SLR by a mean +/- SD of 5.5 degrees +/- 6.6 degrees at P1 (P = .001) and 10.1 degrees +/- 9.7 degrees at P2 (P<.001), compared to PF-SLR. DF-SLR induced distal muscle activation and broader proximal muscle contractions at P1 compared to PF-SLR. CONCLUSION: These findings support the hypothesis that addition of ankle dorsiflexion during straight-leg raise testing induces earlier distal muscle activation and reduces hip flexion motion. The straight-leg test, performed to the onset of symptoms (P1) and with sensitizing maneuvers, allows for identification of meaningful differences in test outcomes and is an appropriate end point for lower extremity neurodynamic testing.

Changes in flexed posture, musculoskeletal impairments, and physical performance after group exercise in community-dwelling older women.

OBJECTIVE: To determine whether improvements in flexed posture, strength, range of motion (ROM), and physical performance would be observed after 12 weeks of group exercise in older women who because of age are prone to flexed posture and impaired physical function. DESIGN: Pretest-posttest of outcome measures. SETTING: Outpatient academic medical center. PARTICIPANTS: Twenty-one women with thoracic kyphosis of 50 degrees or greater. INTERVENTION: Multidimensional group exercise performed 2 times a week for 12 weeks. MAIN OUTCOME MEASURES: Primary dependent measures of flexed posture included kyphosis, forward head, and height. Other dependent measures included spinal extensor muscle strength; shoulder, hip, and knee ROM; balance; modified Physical Performance Test (PPT); jug test; and gait speed. RESULTS: Baseline kyphosis was 57 degrees +/-5.0 degrees , and age was 72.0+/-4.2 years. There were significant improvements in usual (-6 degrees +/-3 degrees ) and best kyphosis (-5 degrees +/-3 degrees ) (P<.001), spinal extensor muscle strength (21%+/-13% of peak torque/body weight, P<.001), popliteal angle (right, 7 degrees +/-7 degrees ; left, 9 degrees +/-10 degrees ; P<.001), modified PPT (2+/-2 points, P<.001), and jug test (-1.4+/-1.3s, P<.001). Age and modified PPT at baseline correlated with change in kyphosis (r=0.5, P=.02; r=.42, P=.055, respectively). CONCLUSIONS: Multidimensional group exercise reduced measured kyphosis and improved strength, ROM, and physical performance. This study provides a promising exercise intervention that may improve posture and physical performance in older women with flexed posture.