Topics in Geriatric Rehabilitation

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Monday, December 5, 2011

A number of reports suggest that among healthy elderly persons, nearly one third complaint of memory problems.  As our society ages, age-related diseases assume increasing prominence as personal and public health concerns. Disorders of cognition are particularly important in both regards, and Alzheimer’s disease (AD) is by far the most common cause of dementia associated with aging. In 2000, the prevalence of AD in the United States was estimated to be 4.5 million individuals, and this number has been projected to increase to 14 million by 2050.  Although AD is not an inevitable consequence of aging, these numbers speak to the dramatic scope of its impact. Whereas the presence of a subjective memory complaint is a central condition for mild cognitive impairment (MCI), little work has been done to investigate its nature and severity.  Studies have been consistent as to report that individuals with MCI report more memory complaints than controls.

Memory rehabilitation in dementia is gaining importance. Among the increasing number of people affected by AD, the number detected in early stages of the disease is growing quickly. The reasons are obvious: improved clinical assessment in the initial disease stage, increased sensitization of the elderly towards cognitive deficits, and the prescription of drugs retarding cognitive decline. Although skepticism towards cognitive training in dementia is still common among clinicians, given the limited success of early training programs in the 1980s, recent promising studies gave reason for optimism. Memory therapy in the early-to-moderate stages of AD can be successful, if it is tailored to patients' individual daily problems and based on their residual cognitive capacities. In this special issues we are presenting information on  the effectiveness of cognitive training to prevent, amelliorate, and  reduce the progression of age-related cognitive decline in the e lderly

Exercise has been shown to be an effective treatment for cognitive impairment in the elderly. When I conducted a meta-analysis evaluating the effects of exercise on physical and mental function in older adults with cognitive impairments, the results were impressive. The findings showed that older adults with dementia or cognitive impairment who engage in walking, strength or flexibility activities, benefit in terms of physical fitness, cognitive function (d=0.57) and behavior. Improvements were most significant for older subjects that exercised ≥45 minutes per session. A study by Molloy showed that long-term care residents (age >60) improved on 6 of 8 cognitive tests after participation in an exercise program. Palleshi reported a significant pre-post improvement in four cognitive measures, including the MMSE, in 15 older men with mild to moderate AD after 3 months of arm cycle ergometer exercise (3x/wk). Rolland noted that a 5-12 week program of walking/biking activity resulted in significant improvements on MMSE, while reducing behavioral problems in 23 AD patients >70 years old. Longitudinal studies demonstrate that physically active people have a lower risk of developing CI when compared to sedentary people


Over time, the brain can sustain damage from reduced blood flow, oxidative stress, inflammation, toxic substances, and disuse. In the same way that the heart responds to the physiological demands of physical activity, so, it appears, does the brain. Environmental alterations that encourage exercise in male APP/PS1 transgenic familial AD mice, reduces the cerebral amyloid load compared with mice in control environments and this shows a dose response.   We hope that the present issue will lead to a conceptual change in the memory rehabilitation of patients with dementia. Considering the evidence that cognitive and behavioral rehabilitation techniques may be promising in slowing and ameliorating the symptoms of dementia additional studies evaluating cognitive and exercise therapy in dementia could be of great value to the field of AD.


Mark and I are looking foward to your feedback and comments on this TGR issue with special focus on cognitive and exercise training for dementia.




Patricia C. Heyn, PhD


1.    Kelley B J. Petersen RC  (2007).Alzheimer’s Disease and Mild Cognitive Impairment, Neurol Clin 25;577–609

2.    Tsai DH, Green RC, Benke KS, Silliman RA, Farrer LA.(2006) Predictors of subjective memory complaint in cognitively normal relatives of patients with Alzheimer’s disease. J. Neuropsychiatry Clin Neurosci; 18:3, 384-388.

3.    Matthews FE et al . (2007). Operationalisation of Mild Cognitive Impairment: a graphical approach. PloS Medicne, Oct.; Vol.4, Is.10:e304.

4.    Clement F, Belleville S, Gauthier S. (2008) Cognitive complaint in mild cognitive impairment and Alzheimer’s disease. JINS, 14, 222-232.

5.    Onofrei LV,  Wetherington R,  and Heyn PC. (2008)  Mild Cognitive Impairment and PET: An Evidence-Based Approach to a Case Study. Journal of Investigative Medicine 56(1):103–267, 2008.

6.    Heyn P, Abreu BC, Ottenbacher KJ. (2004).The effects of exercise training on elderly persons with cognitive impairment and dementia: a meta-analysis.Arch Phys Med Rehabil 2004;85(10):1694-704

7.      Molloy DW, Richardson LD, Crilly RG (1988). The effects of a three-month exercise programme on neuropsychological function in elderly institutionalized women: a randomized controlled trial. Age and Ageing, 17:303-310.

8.      Palleschi L, Vetta F, de Gennaro E, Idone G, Sottosanti G, Gianni W,  Marigliano V. (1996).  Effects of aerobic training on the cognitive performance of elderly patients with senile dementia of Alzheimer type.  Archives of Gerontology and Geriatrics.  Supplement 5, 47-50.

9.      Rolland Y, Rival L, Pillard F, Lafont C, Riviere D, Albarede JL, Vellas, B. (2000). Feasibility of regular physical exercise for patients with moderate to severe Alzheimer's disease.  Journal of Nutrition, Health & Aging: 4 (2), 109-113.

10.    Sutoo D, Akiyama K. (2003) Regulation of brain function by exercise. Neurobiol Dis;13(1):1-14. Review.


11.    The Alzheimer's Association. (2011). Maintain Your Brain®: The Science Behind the Recommendations. Diet and Exercise. (T


Sunday, August 28, 2011

“Oncology is Everywhere” that is my mantra when I am teaching students and professionals the basic information about Cancer and the evidence-base behind Cancer Rehabilitation. Cancer impacts everyone. Period. Everyone has a story about Cancer, either a personal story or a story of a friend or loved one who has suffered with and conquered or valiantly battled and lost against Cancer. Cancer does not discriminate based on age, sex or race. All are at risk, either from genetic pre-disposition, carcinogenic exposure (voluntary or otherwise) or just simply from the natural fact that our body’s process of DNA and cell replication just plain messes up sometimes.


The statistics are alarming; 1 in 2 men and 1 in 3 women will develop a diagnosis of Cancer in their lifetime.1 Over 68% will survive and go on to live long, full healthy lives and die in old age of something other than this malignant intruder. Cancer survival rates have increased significantly over the last 3 decades as has the sophistication and in many cases the toxicity of the very drugs and interventions used by the medical community to treat the disease. Standard Cancer mitigating therapies commonly include; surgery, chemotherapy, radiation therapy and hormonal drug therapies, all known to instigate potentially to negative sequelae that adversely impact body structure, function, and participation in lifestyle, home, work and community activities. Many of these adverse effects are responsive to and even preventable by rehabilitation interventions.  


Rehabilitation professionals are expert in identifying and treating movement dysfunction and we target restoration of optimal function as our end goal. However, in this population, of patients being treated for Cancer, rehabilitation professionals are hardly present as a part of the patient’s plan of care. Further we are sometimes overcome with fear because we simply do not know what to do to help these patients. How far can we push them with exercise? What are the things that we need to know about Cancer to safely treat them? What are the nuances of Cancer treatment that we should be aware of when treating this population? If someone has had cancer in the past do we have to worry about it? Why?...and the litany of questions from my fellow peers in rehabilitation goes on and on. I have fielded so many of your questions and I understand; it’s a little scary to work with someone who has Cancer or even has a history of cancer treatment. However, we have a phenomenally important role to play with this population2 and I hope you find a better understanding of that role through this issue.


I was thrilled when Carole Lewis (editor of TIGR) approached me and asked if I would be willing to put this special issue together. I practically leaped out of my seat to say yes. In the last decade and a half of my career, I have had the grand opportunity to work exclusively in the world of Cancer Rehabilitation. From clinical work at a world-renown academic medical center to clinical research in a government hospital to leadership roles with the Oncology Section of the APTA, I have had the joy of seeing this field evolve. Further, I am proud to say that I have had opportunities to play a seminal role in that evolution. This issue is a small way that I (really we) can bring to you the marvel of working in this area of practice. My goal is not to have you read this issue and walk away thinking “I want to be a cancer specialist” (although we will welcome you with open arms) my goal IS to have you read this issue and walk away saying “I am going to think differently about every patient that I see”. Because don’t forget; 1 in 2 men and 1 in 3 women that you are seeing for neck pain, balance dysfunction, joint pain, pelvic pain…you name the impairment, it doesn’t matter they will likely have had or will have a Cancer diagnosis. If your patient has a history of cancer you need to know about it and you need to understand how and why it is meaningful to your interventions. If your patients has never had cancer, you should be aware of the risk factors and recommended screening methods to at least have the conversation with them about taking the recommended steps towards better health.

In an eloquently written vignette on Cancer, Dr. Siddhartha Mukherjee notes “Cell division allows us as organisms to grow, to adapt, to recover, to repair- to live. And distorted and unleashed, it allows cancer cells to grow, to flourish, to adapt, to recover and to repair- to live…Cancer cells can grow faster, adapt better. They are more perfect versions of ourselves…Cancer is built into our genomes…Cancer is imprinted in our society…If we seek immortality, then so, too, in a rather perverse sense, does the cancer cell.”3 Forever will we seek to battle Cancer, and as long as the battle wages there will be functional impairments and disability among patients and survivors that are amenable to rehabilitation, and more importantly, in need of the rehabilitation specialist. Your patients deserve to live long healthy lives that are of good quality and they deserve the best from you. Your knowledgebase will be greatly expanded…your horizons too, I think…through this issue.   Welcome to the very gratifying world of Cancer Rehabilitation.

Nicole L. Stout MPT, CLT-LANA


            1. American Cancer Society: Cancer Facts and Figures 2007, vol. 2007, 2007

            2. Stout NL. Cancer prevention in physical therapist practice. Phys Ther 2009;89(11):1119-22. Available from

            3. Mukherjee S. The Emperor of All Maladies. New York: Scribner, 2010.



Saturday, May 7, 2011


Yoga comes by its gentle qualities quite naturally.  It may have begun as an old people’s sport, with attention to alignment, and staying in the same position for lengths of time.  No competition, no shifting movements, and apart from some tangential Tantrics, no body contact.  As such, a certain amount of therapeutics was built into yoga right from the start. 

The physical Hatha yoga we practice in this country also has functioned as a ‘study break’ from the more challenging activity of ancient meditation: reaching out for eternity.  So the active yoga had to be soothing, calming and safe, but able to stretch muscles and joints enough to simulate more hazardous activities.

Yogis of earlier times were often attached to great households where they functioned as resident tutors, physicians and advisers on subjects as diverse as battle strategies and furniture. This gives even more reason to expect yoga to be wise and beneficial in its very core, as well as its historic application.

But we demand more than traditional acceptance in our medicine.  Acupuncture has succeeded where mandrake root and bismuth have not.  The current issue of Topics in Geriatric Rehabilitation uses current medical techniques to evaluate and validate yoga’s effect in specific clinical entities: coronary arterial disease, osteoporosis, rotator cuff syndrome, imbalance, and pain. There is an article here written by a founding member of Dr. Dean Ornish’s group describing their trailblazing confirmation that yoga and lifestyle change diminish cardiovascular disease. 

The issue’s feature article examines a yoga-based method that, in a few minutes, restores nearly full function after a devastatingly severe and surprisingly common shoulder injury: the rotator cuff syndrome.  The authors use X-rays, CTs, MRI and EMG to analyze and confirm the way a single yoga pose retrains an intact muscle to perform the task of the one that is injured in this condition.  In statistical and financial terms, the method compares favorably with other non-invasive and invasive techniques. It is easily replicable. At this writing this method has succeeded with 656 of 727 patients.

The issue also had two ‘meta’ studies, observing and testing two aspects of care that yoga shares with all other treatment options:  Communication and compliance.  One article wrestles with the difficult problem of getting across something (still) quite new to many patient but in language and concepts that are already well-established.  The other article measures patients’ responses to yoga.  Whether it is taking a daily diuretic or staying away from too much salt, getting across your message is only half the job.  The other 50% is getting the patient actually to do what you’ve told them.  Here yoga presents a sizeable advantage to the clinician:  most people seem to like it, dramatically raising the probability of compliance.


What about the side effects?  Recent studies1 find that indeed there are yoga injuries, and as the number of people doing yoga rises, so do the injuries.  However, they are almost unanimously linked to three causes: overenthusiastic students, poor alignment, and inadequate teaching, in that order of frequency. Further, specific injuries can be linked with particular poses, enabling the skilled therapist to configure individual patients’ therapy in a way that accomplishes therapeutic goals but lowers the odds of reinjury. 

Contemporary yoga is taught in classes, an artifact of urban economics. But yoga was handed down from teacher to pupil in a singular chain stretching back for thousands of years and across the vast and rugged expanse of Asia. “Yoga as therapy” may bring the practice back to one-on-one initially, but thanks to accurate modern methods of diagnosis, after initial evaluations, small groups may be able to work together.  Due to the striking gestalt of its memorable postures, and the fact that people like it, unsupervised home exercise programs that incorporate yoga are likely to succeed.


1.    Fishman, LM, Saltonstall, E, Genis, S. “Understanding Yoga Injuries.”  Journal of the International Association of Yoga Therapists.  October, 2008. and October, 2009.


Loren M. Fishman, M.D. B.Phil.,(oxon.)

Volume 27 Issue 2

Tuesday, February 15, 2011

As issue editor for the January-March Issue of Topics in Geriatric Rehabilitation, I am excited to share this comprehensive overview of the end of life care. This issue includes contributions from the leading clinicians, educators and researchers in end of life care, and will be provide the rehabilitation professional with valuable information to enhance the quality of care for persons facing the end of life. I hope that you will be moved, informed, and inspired by their writings.


Karen Mueller, PT, PhD, Issue Editor, TGR Volume 27(1), Jan-Mar, 2011

Friday, November 19, 2010

While providing community-based exercise programs are an excellence way to advocate for one's profession AND to provide a valuable community service, it is challenging to know when professional duty stops and wellness activities begin. Simons, in her article on Legal Issues outlines this challenge very nicely. I'm interested to know how you manage this tight-rope. I try to emphasize that while I am a physical therapist; I am not providing physical therapy services and would actually do a disservice if I provided professional advice without a formal office visit. I also have a "rule" for my classes that I have the participants recite each class "Don't Fall!" This "rule" emphasizes their responsibility in maintaining their safety because it is not a physical therapy session. Any other thoughts? Dale Avers PT DPT PhD Issue Editor
Current Issue: October/December 2010 - Volume 26 - Issue 4