Still going places (1956)

so do today is mrs price's birthday this morning she's 93 yet this and every day of our life is full of chores and plans full of work and a friends nowadays with antibiotics controlling most infectious diseases the physician sees more and more of his elderly patients carrying their years with ease and with grace though mrs prosser has diffused arteriosclerosis and her roommate suffered hemiplegia prolong the steady rhythm of their active lives and because they've kept active despite their infirmities they're still up and about still going places at 93 her palette still seeks out new tastes her eyes find new sights her friends encompass all ages so she keeps fit for life by living by living to the fullest extent of her ability unfortunately the principle of active therapy for elderly patients has not been universally established by the thousands each day the elderly are brought into hospitals or institutions by the hundreds of thousands each year they remain to fill the beds until they and their days in that uncomprehending state that today shadows the final years of an ever increasing portion of our population they're kept safe they're treated kindly and for so many patients this safe kindly treatment those trapped by infirmity can often be equally trapped by safe kindly passive treatment for a number of years the medical staff of this home for the aged has been attempting to build and preserve the functional ability of its residents through a program of active therapy mrs grier's medical record is yes it's quite a list and there's more yet at 91 mrs grier can still laugh at the doctors the joke is really on them for they have found that in her cases and most others the mere listing of pathologic conditions is often a misleading guide to functional ability and should not become the deciding factor in selecting patients for active therapy during her 10 years in the home mrs greer has been encouraged to live fully and actively by doing so she has improved greatly her chances of living still more years of useful life there's been no passive treatment for mr schuster kept active despite the need for double cataract operations he maintains the skill he found in mastering two artificial legs at the age of 79. that was five years ago mr shuster says he's no racehorse but he's still going places mrs klein is back at ironing board again though a stroke completely paralyzed her right side three years ago this ability to sustain recovery is the true measure of success in old age rehabilitation knowing what can be accomplished with patients like these the medical staff of the home evaluates the problems each new resident presents upon admission this is mrs helen lewis aged 80. the chief complaint is left-sided paralysis following a cerebrovascular accident suffered six months ago contracture and deformity are far advanced her medical chart lists chronic diseases that might well discourage any physician but her medical history also states that until the stroke six months ago this now helpless incontinent patient lived despite her infirmities an active self-sufficient life with a married daughter this is medical information of the highest value for it tells the physician that until the present illness interfered mrs lewis had good functional ability that was six months ago the neuromuscular examination of a severe hemiplegic includes a crucial functional test most hemopleges who can lift the heel of the affected leg as little as one inch from the examining table should be able to walk again the patient is now sent for an evaluation by the full professional staff chaired by the director of physical medicine and rehabilitation the evaluation session begins with the discussion of all that is known about the patient reports from the social worker are indispensable and often members of the patient's own family are asked to be present what the physician may hear from mrs lewis's daughter about her mother's past life and daily habits what she may perhaps unwittingly reveal about her own attitudes and fears may tell him quite as much about the case as the medical notes at such times feelings can run very deep on a first examination the patient's initial state of confusion often gives a discouraging impression of both mental and physical capacity mrs lewis is 80 years old so the word that might come first to mind is senility but to use so vague and indefinite term is as unhelpful as it is on scientific the doctor looks first for the possible physical reasons for such emotional disturbances ideally exercises are often begun within 48 hours after a stroke had mrs lewis's rehabilitation been started then she might have avoided such complications as disuse atrophy contracture and depression six precious months have already been lost it's vital to begin the work of rehabilitation quickly lest poor mental and muscular patterns become fixed beyond hope of correction often the patient has a completely erroneous impression about the nature and extent of the illness and resents any suggestion that she could do more for herself mrs lewis is incontinent this is a functional symptom that should be reversible in the majority of cases yet mrs lewis has remained in continents and suffering a stroke her family finds this loss of control more disturbing than anything else the patient too is ashamed one should not attempt to draw definite conclusions about any patient's capacity for rehabilitation on an initial appraisal a much more accurate picture can be gained by comparing these first observations with those made after a few weeks of therapy results of these simple power and range of motion tests however can suggest what practical goals can be given the patient for the immediate future now we can ask mrs lewis would you like to be able to go to the bathroom by yourself she certainly would it would be wonderful the patient's ability to regain self-sufficiency in toilet is the most important turning point mental as well as physical in old age rehabilitation thus the physician has begun to use one of the basic human motivations to support mrs lewis in a long hard fight for independence mrs lewis has made a beginning she has found hope the physical therapist often starts the program of rehabilitation at the patient's bedside first mrs lewis is shown how to shift the weight of our still almost powerless left leg with the right once a patient can do this she can usually be taught to sit on the edge of the bed by herself and with this skill mastered she's well on her way to bridging the gap between bed and chair this takes time it takes training and it takes patience on everyone's part but once mrs lewis can control her wheelchair the whole pattern of her life can be changed and she can avoid what is perhaps the greatest enemy of health in old age unnecessarily prolonged bed rest after a few more weeks of training mrs lewis should be able to go to the toilet by herself then she will be a great deal easier to care for a great deal easier to live with the continued incontinence of adults is a hard thing to bear with however professional one's attitude or however sympathetic one might be with their plight in three weeks mrs lewis's linen requirements have been reduced from 18 sheets a day to an average of four the patient's efforts to get out of bed the mental lift as well as the physical exertion they brought have been a major factor in decreasing her incontinence though mrs lois still has her bad days as well as her good she knows that she's making progress victims of the more severe cerebral vascular accidents those suffering aphasia for example often need help to accept realistic goals without becoming discouraged the few words mr holtz has mastered are a real achievement for him yet his progress can be blocked if the meagerness of these gains is allowed to let them lose heart a cheerful relaxed atmosphere for therapy should be maintained when the patient can be prepared for exercises with light massage radiant heat a whirlpool spirit as well as muscle is relaxed feels good but there is no improvement in muscle tone or function unless active exercises follow movements designed to keep the arms pliable even when loss of their function appears total helps prevent shoulder stiffening and often makes it easier for the patient to bathe and dress mrs lewis is still learning to use her wheelchair its break and pedal routine needs to be absorbed so thoroughly that these movements finally become automatic once they are she will find in the modern wheelchair a freedom comparable in many instances to that of crutch walking use of the chair keeps our whole body active she feels better more like doing those exercises designed to help limbs directly affected by the stroke many of these patients need to regain their sense of balance this slow steady pace is more fruitful than early spectacular attempts at walking that too often lead to falls though independent walking is something mr holtz will probably never know again he lives in a place that's been adapted for wheelchair use door sills have been removed toilet doors widened a stand around the toilet bowl itself is fixed solidly enough for him to use it as a support now we begin to see the results of those long months of training mr holtz has kept his affected arm pliable with pulley exercises so it's now free enough from spasticity pain and contracture to pull the suspenders over it the wheelchair break and pedal routine is now automatic with him so he can stand from his chair and safety he maintains his balance using leg trunk and arm muscles that have been strengthened by exercise sessions between parallel bars the importance of this kind of independence to an elderly patient's well-being mental as well as physical can hardly be overestimated mrs farber wants to be too independent as with many strong-willed elderly patients the fact that she simply can't do many things for herself anymore is the hardest burden our old shoulders must support such people are often difficult to care for might be a good deal easier just to keep them in bed but keeping any patient unnecessarily bed bound whatever their age or infirmity can only be described as an act of medical neglect active therapy is good medicine even for patients who require a great deal of continuous nursing care for mr hubert a victim of rheumatoid arthritis this trip from wheelchair to bed will always be a struggle but just the fact that a patient can make that trip on his own several times a day can reduce the amount of nursing care required by half mr hubert has spent months as a bed fast patient he knows this freedom is worth the struggle for mrs brenner age 95 the world has shrunk almost a bed size but letting her help to feed and wash herself is important by such small means elderly invalids often can be prevented from sinking into the final vegetative state physical medicine is no panacea its work with victims of parkinsonism like misproctor for example is in its beginning stages in all probability substantial relief from this and other chronic illnesses will come from other branches of medicine yet even here the basic principle of rehabilitation can be applied with profit by promoting movement one helps to preserve the ability to move it's sometimes easy to underestimate what patients can do for themselves hard to remember the importance of pride even in such extremities the patient's pride is often a major support miss proctor has not lost her pride mrs jessup is recovering from a long bout with pyelonephritis though antibiotics usually see patients safely through dangerous infections adequate care must go further a few weeks confinement in bed for a patient of mrs jessop's advanced years can lead to the loss of a great part of our functional ability reconditioning should be commenced as soon as the patient is permitted movement it's a good plan to combine these exercises with bathing dressing or going to the toilet for the goal is to help but to regain the ability to do these things for herself for most elderly patients is seldom feasible to schedule exercise sessions punctually on the hour this tends to discourage both the patients and those responsible for seeing that they come getting here on their own is often a struggle a useful one but a period of rest may be required before work is begun therapy conducted on an individual basis is a necessity for those who have suffered strokes fractures or other serious disabilities yet many of the benefits of group therapy can be maintained when a number of patients take their individual exercises in the same room unfortunately many patients are brought to therapy only after deformities have become so rigid that no amount of treatment can bring substantial improvement and by this stage the patient may well reject any attempted therapy any intrusion into our classic life many sick old people when they're brought for the first time to the physical medicine department look upon all its activity in paraphernalia with suspicion seeing a distorted face can send a shiver of fear through his heart feeling himself surrounded by so many who share his infirmities but whose stares reflect none of the accustomed sympathy for his troubles he may shrink even further into himself but when graduates of the department return for a visit everyone gets a lift off of these former patients became friends while occupying the next wheelchair in this very room oh the gossip can be wonderful to hear so as they see progress around them even the skeptical tend to develop a respect for the program a respect bordering on faith and even the most independent need such faith to sustain them through the long months of effort that lie ahead each new patient is given a realistic appraisal of what he can expect to accomplish here mr ostman knows he's hypertensive and has had three cerebrovascular accidents yet gently with cautious moderation his faith in the program is encouraged faith is a vital ingredient in any program of rehabilitation to sustain it the faith of all those who work with them must be equally strong once a professional violinist mr rossman is both afraid and ashamed ashamed of these hands he can no longer control afraid he will lose even more of their use despite all the doctors may be able to do for him in such cases the assistance of a psychiatrist may be indicated indeed active physical programs often become a part of psychiatric treatment mrs gabriel aged 88 has broken her hip an intertrochanteric fracture of the right femur with broad-spectrum antibiotic therapy to prevent post-operative infection an internal fixation was carried out successfully all bones heal slowly and require adequate protein in the diet with vitamin mineral supplements they also need the anabolic effects of androgen estrogen therapy fractures are of course the most common accident suffered by elderly people particularly women whose loss of calcium after the menopause is severe during the long months often required for complete union prolonged inactivity particularly bed rest must be avoided often she needs a considerable amount of encouragement to keep active but if she's been prepared for this from the day of her surgery she can generally be persuaded to cooperate slow yes but just just give her time she'll make it a loose felt boot is a useful device for helping elderly patients remember not to put weight on the affected limb as soon as the patient can sit in a wheelchair more active exercises are begun strengthened by these exercises the patient can push yourself up to standing position between parallel bars here it's easier to exercise the affected limb without weight bearing easier and safer elevated on a wooden block for clearance and in the safety of the parallel bars most elderly patients feel at ease and can maintain a good range of motion today mrs gabriel will be permitted to walk for the first time she's been following a graduated weight-bearing program and serial x-rays now indicate sufficient union because mrs gabriel has been kept active the affected limb kept supple from the day of the nailing this 88 year old woman is beginning to walk independently again 12 weeks after she broke her hip if training has begun early enough and continued long enough to prevent faulty gate patterns most elderly victims of hip fractures can walk normally once more mrs wise is hypertensive and at several coronary episodes before she broke her hip so operative repair was not considered advisable this mentally alert patient faithfully performed active exercises while in traction and today at the age of 81 mrs wise is graduating from her king mrs lois is making progress too as the body ages it does lose muscle tone takes longer to accommodate itself to braces and to learn the new coordinations these require yet the ability of most elderly people to build new muscle and learn new skills is far less limited than is commonly believed to support the flagging spirit to keep hope alive even when the simplest skills seem lost forever this is the courtship of therapy each morning she asks coming up for exercises mr holtz thinks not doesn't feel like most patients like to come to the physical medicine department these sessions offer them a welcome break in the long days often made longer by pain people learn to loosen up have fun together even make jokes about the very infirmities that have brought them to this place some few like mrs farber simply prefer to keep to themselves to keep their everlasting war with infirmity a fierce personal battle mrs farber has osteoarthritis of the lumber spine on both knees generalize osteoporosis arteriosclerosis of the aorta and vessels of the legs and an ununited fracture of the left hip yet she walks once their anger their drive can be properly channeled it's in these difficult or stubborn personalities that one often finds most hope for rehabilitation she knew he'd come mr host just doesn't want to be bossed in his fight to go on these daily arguments with a therapist seem to help out mrs farber forces herself to exercise daily two trips up and back with the rest in between are about all she can manage yet by such means she avoids that bed fast vegetative state that almost certainly would be her fate we can never forget that for the vast majority of elderly invalids this is the alternative to aggressive active therapy all patients need to see that the therapy they receive will help them do something that's important to them in their daily lives those fair best who can go back to work even part-time or can find an active hobby that really interests them when the family unit survives daily chores can often serve well enough the old dependencies even the old irritations they share can be important stimulants and pride pride in one's own room pride in one's appearance such humble things become major weapons in the patient's constant fight against physical and mental deterioration there's achievement for mr holtz when he can believe that the rug he learns to weave trains his finger so he can dress himself as achievement for mrs blick when she can feel those painful stretching exercises help her to comb her hair there's achievement of a sort even for little miss proctor the victim of parkinsonism when she can know her efforts push back the day when other hands must feed her one can expect frustrations indeed the experienced therapist learns to anticipate them tomorrow she knows she will need some other approach to keep mr rossman at work those who work with aged patients must be realists yet they can never discount the power of the human spirit few patients with mrs lewis's capacity for recovery will need long-term institutional care for medical reasons once programs of active therapy are available in every community hospital and through private positions the six months of passive treatment you received following a stroke almost made her a chronic invalid almost yet today mrs lewis is able to go home at 81 years of age she can graduate from the home for the aged her fight with infirmity is far from over yet looking back recalling the bedfast incontinent patient of one year ago who can call it less than a triumph one day most of us each in his time as a fracture a stroke some disability of aging befalls us will understand better how mrs helen lewis feels on this day of the millions of elderly people around us now all but cut off from home from friends from work like ability many could benefit greatly from some program of active therapy when they many more will be able to live on in fullness