Carole Lewis, PT, PhD, GCS, loves the challenge and variety of working with patients who are older. She explains, "Many people don't realize how much fun it can be. There are people over 65 who run marathons and who are competitive skaters. I have had some patients over the age of 90, and even 100. I also have patients in wheelchairs who can't get around without assistance.
"We see people with amazing histories. There's so much involved in treating older patients. Usually they don't have just one problem, they have several," she says. And although that description applies to many of her patients, it precisely describes one of her recent and most well-known-Pulitzer Prize-winning political satirist Art Buchwald.
From running away from home to serve in the Marines in World War II to living in Paris while writing a newspaper column, Buchwald has lived a full, active, and varied life. (See sidebar "About Art Buchwald.") However, in June 2000 Buchwald at age 74 had a stroke that left him unconscious for 2 1/2 months. He jokes, "When you awaken after that long, people expect you to look like Howard Hughes. I came out looking like Jimmy Stewart."
When he regained consciousness, however, Buchwald found that the stroke had affected him both mentally and physically. "I had to learn how to get in and out of a car, use a computer, and cook a meal. I had to start all over again. That's hard. It's as if your brain doesn't have those skills and you need to learn them all over again. It comes back very slowly."
Following his stroke, Buchwald spent more than a month at Georgetown University Medical Center, then nearly 6 months at the National Rehabilitation Hospital, followed by additional physical therapy at Sibley Hospital in Washington, DC. After his discharge from the hospital, Buchwald's doctors suggested additional physical therapy and recommended Lewis, who is president of Physical Therapy of Washington, DC. She describes her practice as "eclectic," with eight other therapists focusing in areas as diverse as sports and women's issues. Lewis herself primarily works with patients over the age of 65.
"I was a fan of Art, and I was delighted," Lewis says.
As she does with all patients, when Buchwald arrived, Lewis asked him to describe his goals. Lewis says, "My first question was: 'Why are you here to see me?' Art had been tripping, and had some history of falls. He was concerned that he would injure himself. In addition, his endurance was fairly low. We performed a balance and walking test on him and found that he was unsafe. We also looked at his strength and range of motion, and found limitations that could cause problems."
Additional tests showed that Buchwald was significantly weaker on one side than the other. He also was weak due not just to the stroke but also to age and inactivity.
Regular Checkups
Although Buchwald was referred to Lewis following his stroke, she strongly believes that all people who are older should schedule regular visits with a physical therapist (PT). She explains, "Just like we go to the dentist to get our teeth checked, older people should go to a PT. One study showed that the major predictor of a person's ability to perform activities of daily living is a strength measure.1 So why don't older people get a dynamometry test? Although, with increasing age, it becomes more difficult to build strength, it really never is too late. On the other hand, older people can see the results of a strength training program faster than a young person. I'd love the President's Council on Physical Fitness and Sports to suggest that people who are elderly go for a strength test. Unfortunately, too often we seem to react, rather than act before something happens."
In addition to strength, Lewis also would like to see more attention paid to balance. "Art had trouble with static and dynamic balance, like 90% of my patients. Other studies show that if you put people on a program to improve their balance, you could reduce their rates of falling.2, 3 We as a profession should be going into the community and explaining what we offer. That's why I believe that people should go to PTs for annual checkups," she says.
Based on Buchwald's test results and goals, Lewis tailored a program for his specific needs. Buchwald's calls for three sessions a week. Each involves many different elements. Lewis says, "Usually, he warms up on a recumbent stepper and works on his reciprocal movement in his right and left extremities. His warm-ups started at 2 minutes; now he's up to 20 minutes. Then we do joint mobilizations to his hip, knee, and ankle to loosen up his joints. Then we do stretches for both his hamstrings and calf muscles. After his stretches, we do a strength training program for his quads and hip abductors. His flexors were weak at the beginning, but they aren't any more. Then we work on gait and balance, starting with intrinsic balance and then moving to extrinsic balance. I work with him on shuttle walking, turns, and walking on different surfaces to address his balance. Then we do some proprioceptive training."
Exercise...And More
Buchwald's visits range from 45 minutes to over an hour, which Lewis describes as "not particularly long, though not short, either." However, they can be taxing for the 76-year-old Buchwald. During one session, Buchwald teases Lewis, claiming she enjoys inflicting pain. But out of her earshot, he confides, "Physical therapy helps. It's not difficult because I know it's going to help me. They know how to treat you. Three times a week is a lot for me, but I do it and I feel better afterwards." Then he adds with a smile, "If she causes pain, I forgive her." He also admits, "It's probably the most exercise I get."
Lewis says that Buchwald's lack of exercise isn't uncommon, especially for those who are elderly. She explains, "For the current generation of older people, exercise just isn't part of their life. So a lot of these people aren't oriented to exercise. We can cite studies on the benefits of exercise to reverse many of the side effects of aging. The 'inevitable' wheelchair or rocking chair isn't inevitable any more. Much of my time is spent convincing patients that exercise is not just a 'nice thing' or a 'maybe,' but a 'must.' They have to commit to it.
"I tell them I myself am very committed to an exercise program. In the gym, patients can see this level of commitment in others who are working out. Some patients start in a passive mode: 'You don't feel good, then you go to a doctor.' I want to show them: 'You and I are partners. You can feel better, and we can work toward those goals together.'"
Buchwald's program calls for him to perform stretches and other movements between appointments. That's especially important because Buchwald travels frequently, making his schedule irregular. However, he has turned that into an advantage, taking great delight in adapting one of his exercises-a Tai Chi movement called "Crane Takes Flight"-for use in airports during his travels.
"Crane Takes Flight," as the name suggests, involves extending the arms outward, then gently "flapping" them. Buchwald is sometimes searched by airport security officers with handheld metal detectors. The required search position, with arms held outward, closely resembles "Crane Takes Flight." Buchwald, when subjected to a metal detector search, extends his arms and then begins a gentle flapping. He calls it his "airport exercise."
Nevertheless, with his busy schedule, Buchwald isn't always able to exercise as frequently as he should. During one physical therapy session, when asked which exercises he performs at home or when traveling, Buchwald immediately responds, "All of them." Privately, he admits that Lewis can tell when he hasn't kept to his exercise schedule.
Buchwald has been making steady improvement, both mentally and physically. He concedes, "For about a year and a half, I don't think I was very sharp." He now writes two columns a week, lectures and travels, and has a steady stream of books in the pipeline. "It all came back," he says.
"We're working on progressing him to the end point of his goals," Lewis says. Buchwald's main complaint is with some lingering weakness in his right leg. He adds, "It's nice under Medicare that they'll pick up the bill until you get better." Although that's currently the situation, it's only temporary. In 1997, Congress imposed a $1,500 cap on Medicare outpatient therapy services. Congress has delayed the cap until the end of 2002. Pending legislation (HR 3834, the Medicare Access to Rehabilitation Services Act) would repeal the $1,500 cap. The House of Representatives recently passed another bill (HR 4954), the Medicare Modernization and Prescription Drug Act of 2002, that would extend the moratorium for another two years.
Lewis comments, "Art's a perfect example of someone who continues to improve with physical therapy. If the $1,500 cap had been in place, he would have exhausted those benefits and not made the degree of improvement we've seen."
Into the Future
Lewis sees a number of changes coming for physical therapists who specialize in geriatrics. The first is the attitude of the patient. She explains, "Our generation [the baby boomers] is very exercise-oriented. Meanwhile, the Janet Jacksons and Britney Spearses are influencing the next generation. People want what we [physical therapists] can provide-how to feel better, especially without taking drugs that have side effects."
She adds that the surge of baby boomers-the first of whom turn 65 in 2011-will lead to a growing demand for geriatric specialists. "Jules Rothstein [editor of Physical Therapy] put it this way, 'We must look to the massive number of Americans who in the next 2 decades will go from being the baby boomer generation to being the largest geriatric population our nation has ever seen. Maintaining the status quo will not be enough when the boomers begin to devour health care resources like locusts devouring wheat.'"4 Lewis says. Physical therapists should be prepared for the demand...and the opportunity.
Lewis also believes that a growing number of PTs will come to share her enthusiasm for working with patients who are elderly. She cites one study, for example, that found that as students, only 25% of future PTs said they intended to work with the elderly, but as practitioners more than 60% work with this population.4 And this enthusiasm will be fueled by the elderly. Lewis explains, "Many of them have been told, 'There's not much you can do.' So when you help them--and not tell them to 'just live with it'--they're so appreciative."
Buchwald echoes that thought. "The physical therapists who have worked with me have been very encouraging and very upbeat. Their attitude helps me, and it makes for a shorter hour of physical therapy." He adds, "Physical therapy is a tough business, so if you can make fun, too, they [the physical therapy staff] like that. They do help. They maintain I was an 80-pound weakling, and now I can beat up Arnold Schwarzenegger."
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Donald E Tepper is Editor. He can be reached at donaldtepper@apta.org.
References
1. Brach JS, VanSwearingen JM. Physical impairment and disability: relationship to performance of activities of daily living in community-dwelling older men. Phys Ther. 2002;82:752-761.
2. King MB, Whipple RH, Gruman CA, Judge JO, Schmidt JA, Wolfson LI. The Performance Enhancement Project: improving physical performance in older persons. Arch Phys Med Rehabil 2002;83:1060-1069.
3. Hauer K, Rost B, Rutschle K, et al. Exercise training for rehabilitation and secondary prevention of falls in geriatric patients with a history of injurious falls. Journal American Geriatric Society 2001:49(1):10-20.
4. Rothstein JM. Sex appeal. Phys Ther:2002;82:238.
