The UK faces a large increase in its older population, which will inevitably make even greater demands on primary care.1
A considerable number of people over 60 years of age, while mentally active, experience a combination of pain and musculoskeletal disability.
Research shows that only about 20% of the loss of muscle power and endurance is due to the ageing process. Pain in any muscle group is associated with 25% loss of muscle per week and lack of exercise leads to similar loss. It is worth considering that many older patients may have done little exercise since they were in their 20s.
The GP is often the first port of call for the older generation to discuss health problems, pain or mobility issues. The most effective approach to managing musculoskeletal problems in the community varies, depending on the condition, and may include advising patients on appropriate exercise programmes, managing pain by medication, or introducing additional therapies such as osteopathy.
There are three types of exercise: corrective, resistance and cardiovascular.
Corrective exercise is designed to programme the CNS/muscle interface. In the UK, this is usually devised by physiotherapists, chiropractors or osteopaths, but pilates and yoga are also excellent core stability exercises.
The core stability muscles are spread throughout the central part of the body. They are composed mainly of type 1 fibres and are biochemically extremely difficult to maintain. In other words, if the muscles are not used, they are lost. Any of the corrective exercise disciplines mentioned above can be used. Success depends on the expertise of the physical therapist, who must be capable of dealing with chronic conditions and have good corrective and soft tissue mobilisation skills.
Resistance work with weights produces power, or a short-term explosive energy release. However, this is of limited value in older people. Gardening, for example, a popular activity for many older patients, represents resistance work but often in unhelpful positions, and is more likely to trigger problems, rather than improve them.
Cardiovascular exercise is any form of exercise that pushes the heart rate up into a 'training zone'. This promotes growth hormone release from the pituitary gland. In turn, other hormones are released that target the muscle DNA to produce extra energy-making capacity, but only in those muscles that have been preselected by the central neurophysiology. If activity is performed below a certain level of intensity, the brain does not release growth hormone, so it is very easy to do 'wasted' exercise. This has the negative effect of making patients tired and worsening their pain, but not increasing their level of fitness.
Target heart rate formulae are readily available to help patients assess their levels of cardiovascular performance.
Activity and rest periods
Pacing activity over short periods of time with adequate rest periods is important. This could start with 10-15 minutes of corrective exercise per day, then five to 10 minutes of cardiovascular exercise three times a week.
Activity options include a static bicycle, walking in the shallow end of a swimming pool or walking up a slight incline, initially to be done about three times a week. There should be a day between each cardiovascular exercise session and if the patient is very tired or in pain, the day of the exercise should be moved forward.
It is important to treat any pain exacerbated by the physical exercise or physiotherapy exercises because this could affect the patient's ability to respond and progress.
It is vital that any pain is aggressively treated. Codeine, paracetamol and anti-inflammatories may be used initially. Neurological analgesia can be helpful; for example, small doses of sodium valproate, gabapentin or nortriptyline can be prescribed at night.
It is also worth taking into consideration that thyroid disease and diabetes can blunt the response to exercise. Some drugs, such as beta-blockers, will do the same. Low serum iron levels are unhelpful.
Stronger opioids can preserve musculoskeletal function and their side-effect profile is better than that of NSAIDs. The addiction rate in musculoskeletal conditions is one in 2,500. Low-dose opioid patches are a useful alternative. If sensitivity to medication is a problem, injection therapies, such as facet joint injections, epidurals or radiofrequency procedures, are available. TENS, acupuncture and local anaesthetic patches may also help.
There are a number of effective treatment pathways that can be implemented to help keep our ageing population moving and primary care has a key part to play in helping patients to manage these conditions as they age.
There are a number of key points to bear in mind. To prescribe an exercise programme, a clear diagnosis is required and pain and any other related medical conditions which might prevent the patient from responding to the programme must be effectively treated.
The literature shows a good response to exercise up to the age of 80, avoiding unnecessary hospital admissions or surgery.2,3
- Dr Outhwaite is an orthopaedic medicine physician, Oxford University Hospitals NHS trust and at the London Orthopaedic Clinic
1. UK National Statistics.www.statistics.gov.uk/hub/population/ageing/older-people/index.html
2. Singh MA. Exercise to prevent and treat functional disability. Clinics in geriatric medicine 2002; 18(3): 431-62.
3. PAL KE, Paluch AE, Blair SN. Physical activity for health: what kind? How much? How intense? On top of what? Ann Rev Public Health 2011 21; 32: 349-65.