BY JOAN TIMPSON | Article Featured on Sunrise Care
As senior citizens age, their bodies become increasingly vulnerable to conditions that decrease mobility and cause chronic pain. One of the most commonly experienced diseases that impacts the joints and muscles of older adults is osteoarthritis, which affects approximately 8.75 million people, according to Arthritis Research UK. As a result of osteoarthritis and other forms of arthritis, many senior citizens turn to knee replacements for relief from pain and to regain mobility.
Article by Steven J. Atlas, MD, MPH | Article Featured on Harvard Health
Despite being a less common cause of low back pain, sciatica is still something I regularly see as a general internist. Primary care doctors can and should manage sciatica, because for most individuals the body can fix the problem. My job is to help manage the pain while the body does its job. When a person’s symptoms don’t improve, I discuss the role of surgery or an injection to speed things up.
What is sciatica?
Sciatica refers to pain caused by the sciatic nerve that carries messages from the brain down the spinal cord to the legs. The pain of sciatica typically radiates down one side from the lower back into the leg, often below the knee. The most common cause is a bulging (“herniated”) disc in the lower back. Discs are tire-like structures that sit between the bones of the spine. If the outer rim of the disc tears, usually due to routine pressure on the lower back, the jelly-like inner material can come out and pinch or inflame the nearby nerve. Sciatica is most common in people 30 to 50.
How do you know if it is sciatica?
The key to diagnosing sciatica is a thorough history and a focused exam. Unfortunately, many patients expect an x-ray or MRI, and doctors, often facing time constraints, order one even though we know imaging tests don’t really help us treat early sciatica any better. The symptoms of sciatica are often worse with sitting or coughing, and may be accompanied by numbness or tingling in the leg. A physical exam can confirm that the sciatic nerve is involved, and I look for weakness or diminished reflexes in the legs that suggest that someone needs early referral to a specialist. (This doesn’t happen often.) With this information, I can make an initial diagnosis and start treatment.
Treating pain… and managing expectations
Many people think (understandably) that the worse the pain, the more likely something bad is going on. However, this isn’t true for sciatica. The body can reabsorb the disc material that is causing symptoms, even for those with severe pain. So, treatment focuses on controlling pain and keeping people as active as possible. If the pain is excruciating, lying down for short periods can help, but prolonged bed rest does not. So once the pain diminishes, I tell patients to get up and start walking short distances. Since sitting increases pressure on the discs in the lower back, I recommend avoiding prolonged sitting or driving. Many people try treatments like physical therapy, massage, acupuncture, and chiropractic manipulation, but evidence suggests that while these approaches may help typical low back pain, they are less helpful for sciatica. Over-the-counter pain medicines like ibuprofen and naproxen can help. When they don’t I may recommend short-term use of stronger, prescription pain medicines.
The good news is that for most (roughly three out of four) people, symptoms improve over a few weeks. Rarely, I’ll find weakness on exam, such as a foot drop, and refer for immediate surgical evaluation. For those not improving after six weeks, surgery is an option. We know surgery can speed up recovery, but by six to 12 months people who have surgery are usually doing about as well as those who decide to just give the body more time to heal on its own. Surgery involves removing the disc material that is affecting the nerve. It is generally a very safe procedure, and while complications are rare, they can happen. What’s more, 5% to 10% of people who have surgery will not be helped by it, or may have worse pain afterwards.
Patients often ask about spinal injections — where steroid medicine is injected into the affected area. It is worth considering for those with uncontrolled pain or for those with persistent, bothersome symptoms who want to avoid surgery. Injections can provide short-term relief. Like any procedure, it has uncommon risks including more pain, and it doesn’t seem to decrease the need for future surgery.
Staying patient-focused… and “hurt” doesn’t always mean “harm”
For most patients with sciatica, it’s worth seeing your primary care doctor. Patients who come in are often scared. Typically, it is pain the likes of which they may have never had. They want relief and, rightly, they want it now. That is the appeal of surgery and injections, but I also know that most will get better with time and can avoid even the uncommon risks of these procedures. When I see a patient in my office I can assess and identify the few who need immediate referral to a specialist. But for most, I try to reassure that hurt doesn’t mean harm, and that my treatments are geared to managing pain and keeping them active while the body fixes itself. For those not improving, I will get an MRI prior to referring for surgery or an injection, if the patient decides that speeding up recovery is right for them. For those who feel that they can manage the pain, I can reassure them that they can delay surgery for up to six months without risking long-term problems down the road.
- Herniated lumbar intervertebral disk. New England Journal of Medicine, May 2016.
- Evaluating and managing acute low back pain in the primary care setting. Journal of General Internal Medicine, February 2001.
- Epidural corticosteroid injections for radulopathy and spinal stenosis. Annals of Internal Medicine, September 2015.
By Len Canter | Article Featured on US News
Exercise is a great way to stay youthful and even turn back the clock on aging. If you’re new to exercise or simply want a fitness reboot, here are ideas by the decade.
In Your 20s: Experiment with different workouts to find what you enjoy. Make exercise a regular habit that you won’t want to give up, even when career and family make heavy demands on you.
In Your 30s: Short on time? Try three 15-minute walks spread throughout the day. To stay fit and retain muscle, do cardio just about every day and strength training two or three times a week. If you’re new to exercise, take classes or have a personal trainer create a program for you.
In Your 40s: Enhance your weekly routine by doing both low-intensity exercise, like yoga for stress relief and flexibility, and high-intensity workouts, like interval training or a spin or kettlebell class, to boost calorie burn and muscle elasticity. Expect longer recovery times after high-intensity workouts, so make sure to get enough sleep.
In Your 50s: Regular exercise remains a must, but ask your doctor for modifications if you have any chronic conditions. Varying your workouts or taking up a new sport will engage your brain as well as different muscles. Get in at least one or two high-intensity workouts a week and try to take active vacations that include favorite pastimes like biking, hiking or even walking tours.
In Your 60s and Beyond: Stay fit and strong to stay independent longer, and stay socially engaged by taking group classes. Stick with strength training, but consider using machines rather than free weights for more control. Water workouts may be easier on joints, too, especially if you have arthritis. But always keep moving. Try tai chi for flexibility and balance, and go dancing for fun and fitness.
The American Council on Exercise has more, including nutrition and sleep requirements by decade.
Gentle movement that’s easy to incorporate may help you live longer and healthier.
STUDY AFTER STUDY HAS shown that exercise can help improve cardiovascular health, stamina and bone density while reducing the risk of chronic diseases like diabetes and obesity. These findings hold especially true for older adults who, by the very nature of aging, are likely to lose muscle mass, strength, bone density, agility, endurance and balance as they age.
It’s a fight against gravity and time, but staying fit over the long term is a goal worth pursuing. Older adults who exercise regularly enjoy more independence and health than those who don’t. So how can older adults incorporate more activity into their lives and what are the best exercises for them? The key is to find enjoyable activities that you can stick with. These can be anything from walking or water aerobics to yoga, dancing, tai chi or simple stretching.
Regardless of the specific activity you may choose to pursue, one key thing to focus on, says Douglas Ebner, a physical therapist at The Ohio State University Wexner Medical Center, is functionality. “I like to make sure that the exercises we do are able to carry over to regular life.” It’s all well and good to do seated stretching exercises, but when it comes time to get up out of the chair, do you have the leg strength to do that? Are you able to negotiate the stairs that lead into your house.
Cultivating the strength needed to complete these everyday tasks can be achieved through the use of various leg exercises, such as using a leg press machine or completing squat exercises, which are elements Ebner says he focuses on with his patients. “Depending on the person, I’ll try to give them some weight to hold onto so that way we can load their muscles to elicit the response we want.”
In addition to focusing on lower body strength to ensure walking ability and reduce fall risk, Ebner says some older adults may also want to incorporate other functional exercises into their routine. “If they’re stronger, then we can work on a motion where they’re picking up a medicine ball or a kettlebell from the ground, as a simulation for picking up items from the ground that they might need to do in everyday life.”
While exercising, another important consideration is avoiding falls. Ebner says falls are a big concern because there’s a direct correlation between falling later in life and life expectancy. A 2017 study in the Journal of Internal Medicine found that one-third of adults over age 50 who fracture a hip die within 12 months of that injury. Hip fractures are also very painful and greatly reduce mobility.
But reducing falls while encouraging exercise raises a dilemma, says Dr. Tanya Gure, section chief of geriatrics and associate clinical professor in internal medicine at the Wexner Medical Center. “There can be this tension that starts to develop when patients are having increased falls. How do you improve mobility without increasing fall risk?”
Particularly for older adults living in an assisted living community or other long-term care facilities where it may be more difficult to engage in exercises with the support of a therapist in a one-on-one situation, balancing the risk of falling with the need for mobility can be a delicate calculation and a challenge that many assisted living facilities must meet daily. “Sometimes having a concern about falls and a whole system that’s really geared up to reduce falls can ultimately reduce the amount of walking that patients do. That’s a dilemma. You want to encourage mobility and encourage residents to maintain their walking,” says Gure. That’s why it’s important to find the right level of physical challenge with the appropriate level of safety.
Here’s where Gure says families can play a key role in helping a senior stay as active as possible for as long as possible. “Families play a critical role in being there and serving as partners with staff at a facility” and helping keep seniors active outside of organized exercise classes and events. When the family is there, you can ensure that your family member walks more. This kind of support and encouragement can go a long way toward helping a loved one maintain mobility and independence. “To the extent that it can be optimized, families can play a critical role in keeping that going,” Gure says.
In finding the right exercise routine or activities for your loved one, a match also needs to be made between the individual’s abilities and interests. Sue Johansen, vice president of partner services with A Place for Mom, a senior referral service based in Seattle, says “it goes back to ensuring that the activity level of the resident is in sync with the programming at the community. If someone is in a walker, do they have a sponsored and hosted group that goes walking every day? Different levels of care may mean different things; there are some senior communities that have resident-led walking groups in the morning. For those for whom it’s appropriate, it’s great. They can decide where their walks are going.”
But she notes participating in certain exercise groups isn’t always as straightforward a prospect as it might seem on paper. “Senior communities often act like a high school – there are cliques and joiners and people who are leaders. So, for active people, they tend to self-select and gravitate to others that they feel comfortable doing activities with.” This is great if your senior is outgoing and active already. But if you’re trying to encourage an aging adult to get moving more, that might require a little more effort on the part of the caregiver to draw that person into more activities and exercise groups.
And exercising with peers should be part of the program. Gure says exercise is about more than just getting the blood moving and maintaining range of motion – it’s about social interaction, too. Exercise has been shown to be helpful in combating depression, and so has reducing social isolation.
Group exercise classes for seniors often involve stretching or yoga – gentle movements that provide benefits through relaxation as well as improved range of motion. “The degree of intensity of that would depend on where you are (physically) and what kinds of programs are available. I would characterize it as being on the lighter side,” Gure says.
However, some residents in assisted living communities and nursing homes need more intensive rehabilitation before they’re ready to engage in group exercise events. In these cases, Gure says she will discuss with families “concerns about limitations in that person being able to engage in an exercise program.” An assessment of current ability and what it’ll take to get the person’s physical status up to a level that allows them to participate with other residents can be a smart way to help them integrate into the community and get back to a more regular exercise routine.
The goal of any exercise program for older adults should be on improving or maintaining day-to-day function and quality of life. Because of this, many communities will offer exercises that are geared toward helping people maintain mobility while reducing the risk of falling. Seniors who are a fall risk may be able to engage in modified exercises while seated.
In nursing homes, because residents tend to have more health needs than residents in assisted living facilities, the type of exercise you’ll find may be more limited. The focus in nursing homes may be more on providing physical therapy to help residents recover from an illness and become stronger and more independent. But that all “depends on where the person is in their long-term stay,” Gure says. “When a patient initially comes in, sometimes the reason for that is subacute care, where physical therapy services are part of the benefit. The patient is there to gain strength. If there is a decision to either not continue in that subacute care setting because benefits have run out or there’s not an additional benefit needed through rehab, then that long-term resident has more of a restorative exercise program.”
Gure says that physical therapy may be helpful for some patients depending on the situation. “Many times, those patients are at baseline and not physically able or have other limitations cognitively that would make it more difficult for them to engage more independently in an exercise program than a resident who’s in an assisted living facility.” In these instances a “more structured setting where there’s more supervision and a dedicated schedule for that tends to be more what you see when it’s a long-term care resident.”
That said, many nursing homes do have recreational programs that have “wonderful activities that residents can participate in,” Gure says. “There may be some patients in nursing homes who have more free use of the gym to maintain their fitness, but exercise tends to be a much more structured activity in nursing homes.”
When determining what aspect of fitness needs the most focus, Ebner says he evaluates patients first, but that this evaluation doesn’t vary much from what he would conduct for a younger person. “I’ll check to make sure that all the joints are moving the right amount and make sure that their muscle strength is appropriate. Depending on what I find, I may give them specific stretches and exercises to work on that impairment.” But as far as the evaluation itself goes, “it really doesn’t change much between older adults and younger people. I always look at how the joints and muscles are working.”
Ebner says a focus on strength training is important, but that cardiovascular exercise is also beneficial, especially for older adults who have to face a lot of stairs in day-to-day life. Whereas navigating a couple of steps to get into the house might rely more on strength, climbing a longer flight of stairs to the second level may also require some stamina and endurance that cardiovascular exercise can help build.
No matter the specific needs, the name of the game with exercise is to make it a lifelong habit. Ebner says the seniors who do better are those who’ve been active all along and aren’t starting from scratch in building strength and endurance later in life. “The more they can do proactively to keep from losing their strength, the better.” Strength training, balance work, yoga, walking – any and all of these activities can help you lead a longer, less frail life, because having “optimal strength will prevent them from having any major injuries or a fall.”
Even being bedridden is no excuse to skip the sweat session, Ebner says. “Anything can be valuable. (Bedridden patients) are going to be limited in what they can do, but the main thing is you want to get them weight-bearing,” or working to build up the strength to be able to get up out of bed. This may require intensive one-on-one physical therapy sessions, and “if they’ve had surgery they may not be able to. But a lot of times it’s just getting them to do whatever they can do.” It seems when it comes to exercise, no matter your age, something is always better than nothing.
“The big thing is that the more people can strength train at a younger age, I think it sets them up for better success down the road,” Ebner says. While there might be a negative cultural connotation associated with strength training as being only for body-builders and “meathead” types, he says this isn’t what strength training is about. It’s about helping you maintain function as long as possible. “The stronger you are, the more likely you’re going to be able to have longevity.”