THERAPY &
PRACTICE

 
Training in neurology and geriatrics

Using various neurological and geriatric diseases, we want to show how effective exercise can be designed. In this instalment we will deal with exercise adapted for older people. The goal of exercise in geriatrics is to enable elderly people to enjoy optimal independence and quality of life. But why should elderly people train?

Sabine and Hans Lamprecht

Everyone gets older, but everyone ages differently 

It is a fact that old age brings physiological changes that affect people to a greater or lesser extent. These physiological changes include a decrease in muscular performance through a reduction of capillaries and mitochondria and reduction of muscle mass. From the age of 50, the musculature decreases by approximately 0.8% annually; between the ages of 50 and 60, muscle strength decreases by approximately 1.5% every year, and by approximately 3% a year thereafter (sarcopenia). In a new meta-analysis, prevalences between 9% and 51% were found in people over 60 [5]. With age, type 2 fibres (fast-twitch fibres) in particular decrease, the number of motoneurons decreases and we find an increase in the proportion of fat in the muscle [1, 3, 7]. Reduced muscle strength in the lower extremities is associated with a higher risk of falling and a lower walking speed. 

Strength training for healthy muscles 

Maintaining muscle health in old age is possible through regular strength training combined with a protein-rich diet. Seniors should exercise three times a week and the exercise session should last 20 to 45 minutes. Warm-up and cool-down should be longer than for young people. Optimal warmup activities should last 15 to 20 minutes, while 10 to 15 minutes are set aside for the cool-down phase [4]. Continuity is of course crucial for the success of the training. This means that therapists must create situations for seniors in which the enjoyment factor is not neglected. 

How can this be implemented effectively in practice? A movement exerciser, such as the THERA-Trainer tigo, is ideal for exercising at home or in a retirement home. It is important to take a targeted approach. 

Targeted endurance and strength training 

Endurance training involves exercising with minimal resistance, but for a long time – 15 minutes or longer. This can also be done as interval training, i.e. with short breaks of 5 minutes, for example, and another subsequent interval. Of course, in the case of certain preexisting conditions, such as cardiovascular conditions, the watt values recommended by the cardiologist should be observed, if necessary. It should also be noted that geriatric patients in particular are often prescribed beta-blockers, meaning that pulse-controlled training is often not useful or useful only to a limited extent. Apart from this, endurance training should be designed individually with an experienced therapist. In regular endurance training, three intervals are used. 

As we know that strength plays an important role in geriatrics, it is essential that a movement exerciser also trains strength in a targeted manner. Here too, it is important not to be too cautious, but to use as much resistance as possible and rather reduce the duration or number of repetitions [2].

Exercising arms or legs 

For both endurance and strength training, it is important to carefully consider whether to exercise arms, legs or both. Of course, walking requires more leg strength, but endurance training can be done with both arm and leg activity, and arm strength is also an important factor in preventing falls. Training with a movement exerciser must be individual, targeted and carefully thought out in order to achieve the greatest benefit for the patient. 

In a retirement home, group exercise with a cycling device, such as the THERA-Trainer tigo, is a good approach, as it is ideal for exercising together or even for some friendly competition. Group exercise with the tigo is a lot of fun. It has been shown that participants not only exercise for longer and more intensively, but also that they find the exercise less stressful – even in retrospect. 

Performance limit 

We should exercise at our performance limit. This is how we achieve the best possible success. What does this mean for geriatrics, where it is not always possible to control exertion via the pulse? Signs indicating that an older person is really exerting themselves or is exercising sufficiently include: 

  • Increased breathing rate – out of breath 
  • Flushed face 
  • Sweating 

Motivation for successful therapy 

It is crucial that the patient receives feedback on the progress made. When patients achieve success, dopamine is also released, an important neurotransmitter which brightens their mood and helps with motor learning. These successes can also be achieved without devices, but therapists or relatives must then provide the necessary framework conditions. A fun and encouraging atmosphere, plenty of praise and a little competitive spirit are all helpful in motivating neurological and geriatric patients. Those supervising should offer plenty of praise to the exercising patients and report back to them clear improvements based on figures[6]. 

 

Balance trainers in geriatrics 

Persons who cannot stand alone can exercise very successfully using a balance trainer, such as THERA-Trainer balo. Effective cardiovascular training, strength training and targeted balance training are all possible with the balo. Both the balo and coro are particularly suited to reactive balance training. Problems with reactive balance are primarily experienced by Parkinson’s patients, but also by other geriatric patients. This can be tested using the pull test. The patient stands, the therapist pulls the patient back (slightly) by the shoulders and quickly lets go. The patient must take balancing steps. If the patient finds this difficult, they can practise balancing steps successfully in a safe environment using balo or coro. Ideally, patients should exercise on the sagittal plane, i.e. steps are taken forward and backward. 

If the spring resistance is increased, strength can also be trained specifically in step position, for example. The following muscles in particular are required for walking:

  • Foot flexor – exercising behind the vertical activates foot lifter 
  • Calf – pushing the body forward 
  • Thighs – one-legged knee bends 

In general, the balo can also be used to do standing-up exercises for transfers. It is easier to transfer from standing to sitting and back up again, and to exercise in small steps with a lot of repetition. Later, patients can practise standing up from a seated position by pulling themselves up, e.g. using a table, or by using the belt system. Standing up while using the side rails for support can be a goal for fitter patients. 

Of course, the balo also has all the advantages of a conventional standing frame: 

  • Contracture prophylaxis 
  • Pneumonia prophylaxis 
  • Thrombosis prophylaxis 
  • Improved alertness and thus improved awareness and cognition 

Balo and tigo are devices that no nursing home should be without, perfect for a small exercise/ fitness room. If there is a lack of space or more supervision is required, both can also be placed in a corridor. 

Therapists, both outpatient and in hospitals, should bear in mind that patients can perform targeted exercise, also at home, with the help of these devices. In this way, both the self-efficacy and the exercise dose can be increased. This leads to better treatment success and helps to prevent deconditioning, which is a particular concern in geriatrics and which can occur rapidly. 

Older people need more targeted training – not less 

A note on gait training with lyra in geriatrics: Walking can be trained in this way as needed, such as for patients who were immobilised for a long time after an operation or as a result of internal problems, and who can therefore no longer walk even with aids. If the goal is for these geriatric patients to walk again, the lyra is the right exercise device and the following procedure should be followed: as much and as often as possible, but at least three times a week. 

If the focus is on walking endurance, this can also be trained in the lyra using interval training, as well as walking speed, balance and dual task. To train walking speed, the lyra should be adjusted as soon as possible. In geriatrics, the performance limit must be considered (see above). During balance training, the patient may only hold on to a TheraBand or similar. 

Lyra, balo and tigo are therefore excellent devices that should be used for targeted training in geriatrics.

 

LITERATURE

[1] Brown WF (1972). A method for estimating the number of motor units in thenar muscles and the changes in motor unit count with ageing. In: Journal of neurology, neurosurgery, and psychiatry. 

[2] Liu CJ, Latham NK (2009). Progressive resistance strength training for improving physical function in older adults. In: The Cochrane database of systematic reviews (3), CD002759. 
[3] Nair KS (2005). Aging muscle. In: The American journal of clinical nutrition 81. 
[4] Nayak N, Randall K, Shankar K (1999). Exercise in the elderly. In: Shankar K, editor. Exercise prescription. Philadelphia: Hanley & Belfus; 1999. p 333-4.
[5] Papadopoulou SK, Tsintavis P, Potsaki P, Papandreou D (2020). Differences in the Prevalence of Sarcopenia in Community-Dwelling, Nursing Home and Hospitalized Individuals. A Systematic Review and Meta-Analysis. In: The journal of nutrition, health & aging. 
[6] Rosenzweig MR (1966). Environmental complexity, cerebral change, and behavior. In: The American psychologist 21 (4), pp. 321-332. 
[7] Verdijk LB, Koopman R, Schaart G, Meijer K, Savelberg HH, van Loon LJC (2007). Satellite cell content is specifically reduced in type II skeletal muscle fibers in the elderly. In: American journal of physiology. Endocrinology and metabolism.

Autoren


Sabine Lamprecht and Hans Lamprecht and Hans Lamprecht have been working as physiotherapists since 1980 and 1982 respectively. After working in different hospitals, they opened their own physiotherapy practice with a neurological focus in 1987. After moving the practice to new premises in 2019, they were able to offer a wider range of therapies as an interdisciplinary practice with physiotherapy, occupational therapy, speech therapy and medical training therapy. After completing her Master’s degree in neurorehabilitation in Krems, Austria, Sabine Lamprecht was responsible for the development of technical concepts in physiotherapy, occupational therapy and sports therapy as Head of Motor Skills at Schmieder hospitals. Sabine and Hans Lamprecht are internationally active as lecturers and speakers, and offer advanced training courses on neurorehabilitation and geriatric rehabilitation.