September 19, 2011

INDIA: Pune doctors helping the elderly stand on their feet

PUNE, Maharashtra / The Times of India / Life & Style / September 19, 2011

By Umesh Isalkar, Times News Network

The role of a physiotherapist in helping an accident or a stroke patient walk again is known. In fact, several hospitals today have a separate physiotherapy department. However, despite having a sizable graying population, the city does not have a dedicated physiotherapy unit for the old people.

Some physios in the city are slowing but steadily building up facilities that help improve balance, strength, mobility, and overall fitness in old people, besides helping them maintain their independence for a longer period of time. This at a time when there is no formal course in geriatric physiotherapy and subsequent lack of such a facility in hospitals across the country.

"Inability to walk or frequent falls are common complaints among old people. Their primary expectation is that they should be made fit enough so that they can go to the toilet on their own," says Gajanan Bhalerao, a consulting neurophysiotherapist at the Sancheti Institute College of Physiotherapy.

Bhalerao says that they help them walk with or without ambulatory assistive devices like a walker, a cane or crutches. However, the focus is always on safety. "A patient walking with assistance is okay but he should not fall," says Bhalerao, who has been active in geriatric rehabilitation for the last eight years.

"An old man, like a child, needs a lot of attention and understanding. Their associated physiological and psychological problems need to be considered and understood while deciding the management of their ailment," says Apurv Shimpi, a consultant physiotherapist and an associate professor at the Sancheti Institute College of Physiotherapy.

"Ours being an orthopedic institute, most people come here with problems like fractures due to fall or wear and tear of joints. But they also have balance disorders, nutritional neglect, depression, loss of zeal, which need to be understood to gain a proper rehab," said Shimpi, who has been teaching and practising geriatric physiotherapy for the last seven years.

Some patients struggle to walk. "Elderly patients struggle to use public transport, crossing traffic signals and climbing footpath because they cannot lift their legs to get on the pavement," said Shimpi.

Archana Phansalkar, a member of the Team Physiotherapy Services at Nivara old-age home says, "We have a sizable number of people above 60 years of age. They suffer from illnesses that restrict them to bed. Physiotherapy in form of gentle stretches, mobility training or ambulatory aids helps them walk again and conduct every day activities." A total of 13 physiotherapists work at Nivara's physiotherapy centre in Navi Peth.

The Spinalogy Clinic in Aundh treats about 300 old patients a month.

"Pain in the knee, hip and back are common. The reason being reduced physical activity after a particular age. They do a few exercises at home in the morning while watching television, but lead a sedentary lifestyle otherwise," says physiotherapist John Franklin of the Spinalogy Clinic.

Besides regular physical limitations, the elderly suffer from heart ailments, diabetes, osteoporosis, to name a few. Parkinson's, balance, respiratory disorders need to be taken into consideration when looking at them in a broader term.

"I had once treated a patient who had recurrent breathing problem. He would frequently catch cold and accumulation of lot of secretions in lungs left him bed-ridden. He developed weakness because he was restricted to bed for a long span of time. Reduced movements of joints resulted in balance problem. So, even while recuperating from his primary ailment, he would often fall while walking. Once he got his hip-bone fractured. He was again hospitalised and advised bed-rest. His condition worsened. When I was called, I had to put all his problems of lungs, muscles, brain and bones in perspective to bring him back to normalcy," recalls Franklin.

Patients suffering from lung and heart disorders cannot be advised exercises that are prescribed to other elderly people. We need to assess how much pressure and stress their heart and lung can bear, he added.

To be a rehabilitation physiotherapist in geriatrics, you need a great deal of patience, stamina, enthusiasm and co-operation from fellow members of the team, says senior physiotherapist Venkataseshan, who is the director of stimulus physiotherapy and fitness centre in Karvenagar.

Recalling a similar story, Venkataseshan said, "An 87-year-old man once came to us complaining of difficulty in walking and performing his day-to-day activities for the last four years due to a left-side stroke. In addition, just a year ago, he had had a total hip replacement on the same side. He was also diagnosed with osteoporosis. When I examined him, he had a lot of tightness in the muscles of hip, knee and ankle. We have been treating him for the last eight months and now he is able to walk with the help of a walker. He can do his every day work and sits on the computer almost daily for two to three hours."

While treating an old diabetic patient, a physiotherapist needs to take into consideration the time when he takes medicines and his eating habits. For an elderly patient with associated cardiac problem, the patient's cardiac status, fatiguability, ability to reach a steady state, at times ECG monitoring also needs to be done.

For patients with osteoporosis, non-weight bearing exercises like cycling and swimming are preferred. But again it depends on the availability and feasibility of using such mode of exercise. Weight training is preferred for strengthening, but that also depends on the condition of joints, Franklin said.

"Patients with diabetes do come with diabetic neuropathy or diabetic foot. Such patients are treated with muscle stimulation for intrinsic foot muscle and also foot proprioception. Balance training is given which helps patient maintain proper gait," said physiotherapist Malhar Borse of the Hardikar Hospital.

Many old people require social and psychological support along with regular physical rehabilitation, says physiotherapist Shweta Bhave. Geriatric patients need an inclusive treatment and not only physical therapy. Treatments such as naturopathy, diet, yoga and stress management play equally important role, Bhave says.

"A 76-year-old woman had undergone bilateral total knee replacement five years ago. She was diagnosed with pneumonia and hypertension and was also obese. She has now recovered completely with physiotherapy. She used to walk only with the help of a walker, that too inside her home and had the 'fear of fall' hence she didn't even attempt to climb stairs or go out of the house. Regular motivational counseling improved her confidence and helped her exercise better. This was possible majorly because of the support she received from her family members and people around," said Venkataseshan, who is a life member of the Indian Association of Physiotherapists (IAP) and also a member of the National Strength and Conditioning Association (USA).

Almost 90% of the elderly are socially and psychologically affected. They are frustrated and fed-up with problems that they have.

"But when probed further, it is usually seen that the atmosphere in their home and their relatives make them depressed. If these patients are ignored in these aspects and are treated, they will not usually give positive signs of improvement unless they are psychologically counselled," said Franklin. Despite having a sizable elderly population, our country does not have a dedicated course or a structured module on geriatric physiotherapy.

"Geriatric physiotherapy is not looked upon as a lucrative field in India. In the west, geriatric rehab is managed by social security or medical insurance. This, unfortunately, is not the case in India. Many old patients are not financially competent. Also, the improvement seen is at times very slow or depressing. That's the reason why we have very few physios in this field," said orthoapedic surgeon Parag Sancheti. "We are in the process of starting a geriatric rehab unit as well as a geriatric day care center at the Sancheti Hospital," he added. Experts in the field emphasis that majority of age-related problems can be solved by following proper exercise and diet regimen.

To ensure a good, healthy and quality life, the elderly members of the society can move a long way with the support of the family members as well as the society. "Physiotherapists play a very important role in rehabilitation and treatment of these elderly population," said orthopaedic surgeon Abhay Kulkarni (right).

"Physiotherapy should be made the way of life once bones and joints start ageing. Degenerative problems are best prevented and treated with physiotherapy. There is a need for formulating special courses and education modules in medicine and physiotherapy for geriatric population as we have for Paediatric," said spine surgeon Kiran Shete.

About greatric physiotherapy

* Alzheimer's, arthritis, balance disorders, cancer, cardiovascular disease, incontinence, joint replacement, pulmonary disease, stroke, and osteoporosis are only a few of the problems covered by geriatric physiotherapy

* The therapy aims at restoring mobility, increasing fitness, reducing pain, among other benefits

* Geriatric physiotherapy is a proven means for old adults to improve their balance and strength, build their confidence, and remain active

* Falling is one of the greatest risks old people face, often leading to hip fractures which then lead to a downward health spiral

* Falling is such an issue among older adults that the Center for Disease Control and Prevention has reported that one-third of all people over the age of sixty-five fall every year, making it the leading cause of injury among people in this age group

* The National Sample Survey probed into five types of disabilities among the elderly. These are visual impairment, hearing problem, difficulty in walking (locomotor problem), problems in speech and senility. 25% of the elderly in India suffer from visual impairment, followed by hearing ailments (14%) and locomotor disability and senility (11% each).

* The size of India's elderly population aged 60 and above is expected to increase to 179 million in 2031 and further to 301 million in 2051. The proportion is likely to reach 12% in 2031 and 17 per cent in 2051.

* The socio-economic problems of the elderly are nowadays aggravated by factors such as the lack of social security and inadequate facilities for health care, rehabilitation etc.

* Living arrangements of older people are influenced by several factors such as gender, health status, presence of disability, socio-economic status and societal traditions.

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