Since the release of the 2017 Canadian Census, aging, and the onset of the 'grey tsunami' has had a lot of media attention – longer lifespans and a lower birth rate mean that the proportion of adults over 65 in the overall population has been increasing since early in the 20th century[1].

Much of the medical literature on aging has to do with managing or treating disease (acute or chronic) or disability in older adults, and the medical and/or societal cost of providing care.

However, along with recognition of the change in demographics, both research and the public health approach to aging and its challenges are moving in a different direction. There has been a shift to a recognition that aging is a complex, multidimensional and a heterogenous process – and the importance of a biopsychosocial approach to seniors and their health.

Today’s seniors are active, engaged members of their community who contribute to and participate in family and social activities long after paid employment ceases. The focus of the biopsychosocial model is on maintained independence in ‘successful’ or ‘healthy’ aging.

The ‘healthy aging’ model has many domains. The physical domain identifies indicators for mobility and physical function that can predict the onset of functional decline. This in turn will help determine strategies to manage modifiable factors that improve mobility and physical function and delay the onset of functional decline.

Functional decline means loss of independence and ultimately, the onset of complex medical challenges, frailty and increased dependence. Identifying and addressing factors that can mitigate or delay functional decline is a huge step forward in countering its progress and enabling healthy aging across the continuum.

And older adults concur – a 2014 review of qualitative studies of community dwelling adults over 65 found that while mobility may have different meanings to different people, the general theme was that mobility is ‘vital to health’ – it signifies independence, well being and freedom[2]. Mobility is vital; its loss can affect the physical, psychological and social aspects of an older person’s life, including the ability to shop for groceries, (nutrition), attend doctors’ appointments (timely health care), travel, pursue social activities, hobbies or sports and taking care of both self and home.

Limitation in mobility may be the first observable sign of functional decline[3].  

What does this mean for physiotherapy?

From my perspective, what other profession is as well-equipped to assess and treat the modifiable, musculoskeletal factors that put an older adult at risk for loss of mobility? 

Physiotherapists are best placed to conduct a thorough assessment of range of motion, muscle strength and balance. A physiotherapist has the knowledge, skill and ability to determine if: a) musculoskeletal impairments are involved, b) they are amenable to physiotherapy, or c) if referral to the family physician is warranted.

For example, walking speed has been dubbed the ‘sixth vital sign’; it is a valid and reliable means of assessing overall health and functional status in seniors as well as a number of other populations, with identified ‘cut offs’ for predicted outcomes.[4] Joint range of motion, muscle strength and balance are some of the modifiable factors that can affect walking speed. Physiotherapy assessment and intervention, whether in health promotion or as part of an active treatment plan can improve the musculoskeletal factors contributing to walking speed.  For some seniors, referral to a community-based program will be the most appropriate plan.

For example:

  • Cho et al (2012) demonstrated that mobilization of the talo-crural joint in a group of healthy seniors increased ankle dorsiflexion and improved their functional balance when compared to the control group[5]
  • Escalante et al (2001) demonstrated that hip and knee flexion contribute to walking velocity in seniors – those with restricted mobility in the hip and knee were more likely to be the slowest walkers[6] ;
  • Lee et al (2005) determined that age related changes in hip range in community dwelling adults were dynamic, not postural[7];
  • Suri et al (2011) demonstrated that strengthening exercises increased endurance in trunk extensor muscles and improved both balance and mobility in older adults[8]; and
  • Law et al (2016) demonstrated that a targeted exercise program was beneficial in the management of sarcopenia (loss of muscle mass) and dynapenia (loss of muscle strength) and the maintenance of mobility and independence[9].

Management of these (or other) modifiable factors will not only improve walking speed, but will enhance physical function, and support a senior’s independence, the goal of ‘healthy aging’.

Introducing a New Toolkit for Physiotherapists

Physiotherapy Alberta recently released the ‘Healthy Aging – Seniors’ Mobility Toolkit’. It is intended to provide physiotherapists with physiotherapy specific tools to support healthy ageing in their practice.  

The Toolkit can be used in any clinical situation - from within a community-based health promotion program to an active treatment setting in a facility or private practice.

Please note: the Toolkit is not an exhaustive or comprehensive assessment of all risk factors for loss of mobility. It should be used within the context of a broader assessment.  The Toolkit was developed to provide clinicians with familiar tools to screen community dwelling seniors for risk of mobility loss, and provides established, relevant norms and cut point scores for individuals at risk of mobility limitation.

Scores may also help clinicians identify individuals who would benefit from referral for more in-depth assessment or management.

The Toolkit is available through the XChange on the Physiotherapy Alberta website. Both Physiotherapy Alberta and Ignite Physiotherapy provide additional resources for clinicians wishing to develop their expertise in this expanding practice area.

Footnotes: 

[1] Arrigiada P, A day in the life: How do older Canadians spend their time? Statistics Canada 2018. https://www150.statcan.gc.ca/n1/pub/75-006-x/2018001/article/54947-eng.htm

[2] Goins RT, Jones J, Schure M, Rosenberg DE, Phelan EA, Dodson S et al. Older adults' perceptions of mobility: A metasynthesis of qualitative studies. Gerontologist 2015 Dec; 55(6):929-42. doi: 10.1093/geront/gnu014. Epub 2014 Mar 17

[3] Brown CJ, Flood KL. Mobility limitation in the older patient: a clinical review. JAMA. 2013; Sep 18; 310(11):1168-77. doi: 10.1001/jama.2013.276566.

[4] Middleton A, Fritz SL, Lusardi M. Walking speed: the functional vital sign. J Aging Phys Act. 2014;23(2):314-22.     https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4254896/

[5] Cho B, Ko T, Lee, D. (2012). Effect of Ankle Joint Mobilization on Range of Motion and Functional Balance of Elderly Adults. Journal of Physical Therapy Science. 24. 331-333. 10.1589/jpts.24.331. https://www.jstage.jst.go.jp/article/jpts/24/4/24_331/_article     

[6] Escalante A, Lichtenstein MJ, Hazuda HP. Walking velocity in aged persons: its association with lower extremity joint range of motion. Arthritis Rheum 2001 Jun; 45(3) 287-94

[7] Lee LW, Zavarei K, Evans J, Lelas JJ, Riley PO, Kerrigan DC. Reduced hip extension in the elderly: dynamic or postural? Arch Phys Med Rehabil 2005;86:1851-4. http://www.archives-pmr.org/article/S0003-9993(05)00314-X/pdf

[8] Suri P, Kiely DK, Leveille SG, Frontera WR, Bean JF. Increased Trunk Extension Endurance is Associated with Meaningful Improvement in Balance among Older Adults with Mobility Problems. Arch Phys Med Rehabil. 2011;92(7):1038-1043. doi:10.1016/j.apmr.2010.12.044.

[9] Law TD, Clark LA, Clark BC. Resistance exercise to prevent and manage sarcopenia and dynapenia. Annu Rev Gerontol Geriatr. 2016;36(1):205-228. doi:10.1891/0198-8794.36.205.