How to implement an effective and safe program to return shoulder function for patients in their golden years

Upper extremity rehabilitation programs for older patients should focus on restoring shoulder joint functional ability, rather than just chasing arm symptoms. Shoulders have several small joints and numerous muscles (in various layers) that support, stabilize, and move the bones. Since cartilage and tendons provide much of the stability for these joints, the connective tissue is especially important.

This makes the shoulder girdle a difficult region to treat—and it can become a regular source of pain and discomfort associated with neck and upper back problems, as well as most other upper extremity complaints. Rebalancing the shoulder rotator muscles, along with improved scapulo-thoracic posture, can help many elderly patients with upper extremity problems.

Getting Better with Age

When patients over the age of 60 need to regain function in the upper extremity and shoulder girdle, a couple of questions arise. What exercises are appropriate, safe, and effective? Won’t exercising this upper extremity make the problem worse because of degeneration and osteoarthrosis? Obviously, the last thing we want to do for our older patients is to increase their pain or add to their disability.

Degenerative arthritis is one of the most common musculoskeletal disorders in older adults, causing significant amounts of physical disability. Osteoarthrosis afflicts an estimated 20 million Americans, with the spine and weightbearing joints commonly affected and the upper extremity less involved.¹ In addition to pain with movement, the affected joint(s) lose flexibility and strength.

Exercises for older patients must limit overtly painful movements, yet still work to improve flexibility, strength, and balance. Contrary to what is commonly believed, moderate exercise does not increase the risk for osteoarthrosis or exacerbate it; rather, it improves function and reduces pain.²

As we age, there is a tendency to become more sedentary. A national survey by Clark revealed that 70% or more of older adults do not engage in any regular exercise.³ This is compounded by loss of strength and muscle mass, and an increase in body fat normally seen in aging. In fact, this change in body composition is tied to many factors, including poor nutrition, decreased physical activity, increased disability and disuse, type II muscle fiber atrophy, and drug side effects.

The American Geriatrics Society recently reviewed the literature that demonstrates the wide range of benefits obtained when older patients exercise.⁴ The value of resistance exercises for the geriatric population can be seen by the improvements in weight and body composition, decreased falls/improved balance, better psychological health, less frailty, and improved function. These benefits outweigh the concerns.

Dynamic Solutions

Isometric exercises may increase the systolic blood pressure, therefore, isotonic or dynamic exercises are safest for older patients.⁵ Elastic resistance tubing is an excellent method to provide strengthening dynamic exercise for the upper extremity without the need for machines or heavy weights. Older adults often have difficulty getting into and figuring out complex machines and may not be able to handle heavy weights and barbells. A home-based program using elastic tubing can provide significant gains in upper extremity strength and improvements in daily functioning.⁶

A factor that is frequently overlooked when planning exercise for the upper extremity is the influence of posture on shoulder girdle and arm function. Studies by Hertling, Kessler, and Hammer^7,8 support the need to evaluate patients for specific postural distortions that interfere with shoulder function, such as thoracic kyphosis and cervical anterior translation (causing a forward head).

An additional complicating postural factor can be the alignment of the scapula on the thoracic cage—when the shoulder is rolled forward (protracted). Correction of these chronic alignment faults will significantly reduce the biomechanical stress on muscular support for the shoulder. Both of these biomechanical faults are common and become more prevalent with age.

Figure 1. In-doorway stretching exercises.

An easy and effective rehabilitation program starts with a consistent isotonic exercise routine using elastic tubing performing external rotation. This is initially performed within a limited, pain-free range of motion (ROM), building to full range as pain subsides. A stretching program that consists of “in-doorway stretch exercises”⁹ (Figure 1) will progressively improve shoulder flexibility and external rotation ROM. Specific exercises for the supraspinatus muscle may need to be avoided in aging patients, since they tend to further irritate and compress the muscle tendon in the subacromial space.

This inexpensive rehabilitation program should be initially supervised to ensure proper performance. Once good exercise and stretching mechanics are demonstrated, a self-directed program of home exercises is appropriate.

Even the coordination of the lower extremities during gait is a critical aspect of shoulder function.¹⁰ At the same time that gravity and ground reaction forces are affecting the legs and feet, the torso and shoulder are also responding. With each step, the scapula reacts to opposite-leg loading by tipping anteriorly in the sagittal plane, rotating upward in the frontal plane, and gliding around the ribcage in the transverse plane (protraction). This reaction at the shoulder produces the appearance of a hunched and forward-rounded shoulder, described as shoulder pronation. The biomechanical and neurological processes that link shoulder pronation to lower extremity pronation on the opposite sides help us understand some of the previous treatment failures, particularly in aging patients.

Let Research Be Your Guide

The American College of Sports Medicine¹¹ and the National Strength and Conditioning Association¹² have published recommendations for advising older adults about exercise. Both state that aerobic and resistance exercise for older populations are generally safe and can be very effective for treating specific problems and avoiding general disability. These guidelines encourage the use of regular physical activity, along with specific exercises to improve endurance, strength, and proprioception. Fiatarone et al has found that high-intensity training of frail men and women in their 90s is safe and leads to significant gains in muscle strength and functional mobility.¹³

Two outcome assessments for chiropractors include:

• Shoulder injury self-assessment of function questionnaire—a 15-item activities of daily living tool from American Shoulder and Elbow. The patient completes the questionnaire. A score of 0 is considered normal whereas scores approaching 60 represent disability.

• Shoulder pain and disability index (SPADI)—a 13-point questionnaire measuring pain and disability. This scale has been shown responsive to improved and worsened change over time and treatment.

Both questionnaires are copyrighted and require permission to use, which has been obtained by Outcomes Assessment (contact Foundation for Chiropractic Education and Research at: 800-622-6309).

Kim D. Christensen, DC, CCSP, DACRB, founded the Sports Medicine & Rehab Clinics of Washington. He is currently a postgraduate faculty member of numerous chiropractic colleges and is the president of the American Chiropractic Association (ACA) Rehab Council. Christensen can be reached at Chiropractic Rehabilitation Consulting, 18604 NW 64th Ave, Ridgefield, WA 98642, or via email: kimdchristensen@hotmail.com.

References
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2. Casper J, Berg K. Effects of exercise on osteoarthritis: a review. J Strength Condition Res. 1998;12:120–125.
3. Clark DO. Racial and educational differences in physical activity among older adults. Gerontologist. 1995;35:472–480.
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5. American College of Sports Medicine. Exercise prescription for special populations. In: Guidelines for Exercise Testing and Prescription. Baltimore: Williams & Wilkins; 1991:166.
6. Jette AM, Lachman M, Giorgetti MM, et al. Exercise—it’s never too late: the strong-for-life program. Am J Publ Health. 1999;89:66–71.
7. Hertling D, Kessler RM. Management of Common Musculoskeletal Disorders. 2nd ed. Philadelphia: JB Lippincott; 1990:177.
8. Hammer WI. Functional Soft Tissue Examination and Treatment by Manual Methods. Gaithersburg, Md: Aspen Publishers; 1991:31.
9. Travell JG, Simons DG. Myofascial Pain and Dysfunction: The Trigger Point Manual. Baltimore: Williams & Wilkins; 1983:594.
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11. American College of Sports Medicine. Exercise and physical activity for older adults. Med Sci Sports Exerc. 1998;30:992–1008.
12. Pearson D. The national strength and conditioning association’s basic guidelines for the resistance training of athletes. Strength & Conditioning Journal. 2000;22(4):14–27.
13. Fiatarone AA, Marks EC, Ryan ND, et al. High-intensity strength training in nonagenarians: effects on skeletal muscle. JAMA. 1990;263:3029–3034.