An Exercise in Frustration

Just about everywhere you look lately, you’re reminded that 30 minutes of regular exercise several times a week is crucial to good health and long life.

But what happens if you’re one of the millions of older Americans who suffer from arthritis, Alzheimer’s disease, diabetes, osteoporosis or some other physically limiting condition? You may be trapped at home, shut out of traditional gyms and health clubs, too discouraged or too depressed to challenge yourself with movement.

“They’re the forgotten people,” said Karl G. Knopf, president of the Fitness Educators of Older Adults Assn. He’s among a growing number of patient advocates and fitness professionals who worry that the one-size-fits-all fitness world has left behind the very people who may need exercise the most.

The numbers are striking. An estimated 54 million Americans have disabling or chronic illnesses such as asthma and diabetes. Two-thirds of them are over age 60. Almost all could benefit from physical activity.

Exercise has been shown to lower blood pressure and cholesterol, improve sugar metabolism, and boost mood and concentration. It also helps muscle tone, endurance, motor skills and balance. The health benefits, along with the psychological boost of social interaction, can increase independence, staving off some of the deterioration that chronic illness can bring.

Without exercise, the chronically ill risk the setbacks of deconditioning, said Dr. Jeffrey L. Cummings, director of the UCLA Alzheimer’s Disease Center. “If you let people sit in bed, they cannot get up again. You have to maximize your physical activity to reverse [deconditioning] to the extent you can.”

But that’s easier said than done. Only a few facilities can accommodate people with physical limitations. Programs tailored to special needs are scarce, and transportation is sometimes a problem.

And even if an appropriate fitness program is available, health-insurance plans generally won’t cover it. Only a few sick or elderly can afford to pay out of pocket.

Victor Suhr, for example, a 61-year-old former locksmith with post-polio syndrome, can barely scrape together the money for a weekly water class.

When he was still working, he swam 50 laps each day at a Santa Barbara YMCA. But now, cool pool temperatures make his limbs cramp. He lacks the stamina to walk more than a couple of blocks.

Because Medicare won’t pay for warm-water therapy, he scrapes up his one-third share for the class sponsored by the Arthritis Foundation and nearby St. Francis Medical Center. It isn’t enough, but it’s the best he can do.

Insurance poses another impediment, experts say. Many health plans don’t provide physical therapy for chronic conditions. Some have trimmed rehabilitation benefits.

Exercise professionals say none of this will change until health plans, and the federal Medicare program, make exercise a priority.

“It’s going to take some kind of a legislative mandate that would allow Medicare to fund fitness center memberships,” said James H. Rimmer, head of the National Center on Physical Activity and Disability.

The Medical System Can Thwart Access

Access to exercise for those with special needs is often intertwined with--and as a result, often hindered by--the medical system. Doctors may not know what to recommend, and insurers aren’t aware of its value. Because doctors generally receive limited training in exercise’s benefits, they’re less likely to know how, and where, to steer patients.

Some recommend physical therapy, although it is usually a very limited proposition--often just a handful of sessions to get someone through the acute phase of an illness or postoperative period.

“At some point they will be discharged. That’s where we see regression, and people lose the strides they make,” said Janie Clark, president of the American Senior Fitness Assn. in New Smyrna Beach, Fla.

Exercise experts say physical therapy needs to be better melded with personal training, with patients perhaps stretching their half-dozen sessions by having trainers work with them until they hit a plateau or obstacle that requires a therapist’s intervention.

Researchers, meanwhile, are seeking the scientific evidence that could move health insurers to make the benefits more widely available. Already, a few Medicare HMOs incorporate exercise into their wellness programs, but they’re the exception.

The impact of exercise on the nation’s healthy population is indisputable, but specific research has only just begun in the ill and elderly.

“What we are now trying to do as scientists in rehabilitation is prove the evidence,” said LaDora Thompson, an associate professor of physical medicine and rehabilitation at the University of Minnesota. Health insurers are “not going to reimburse for anything that does not have an actual proven research study that said it is truly effective.”

A former physical therapist who now does laboratory research on exercise and cell function, Thompson is among those working to provide proof on a fundamental level.

Other studies are seeking to show, condition by condition, how exercise and movement can restore physical abilities and protect health in people with osteoporosis, arthritis, stroke, heart disease. Even paralyzed patients can benefit, new research indicates.

Gary Dudley, a University of Georgia exercise scientist, has used electrical stimulation to build up the muscles of people who have paralyzing spinal cord injuries. He’s now studying whether bulking up the muscles can improve their health and reverse diabetes and obesity, from which they disproportionately suffer. At the same time, Susan Harkema, an assistant neurology professor at UCLA, has retrained the paralyzed muscles of such patients by placing them in a harness above a treadmill and having physical therapists manually guide their legs.

Not only do the legs relearn how to walk, Harkema said, but “we’re finding that their overall well-being is better, their circulation is better, their muscles change and spasticity decreases.”

Such promising experimental results belie the reality that resources and access are still limited for most patients. That’s slowly changing.

The National Center on Physical Activity and Disability, based at the University of Chicago, is becoming a national resource on exercise and disability. Using a four-year, $3-million grant from the Centers for Disease Control and Prevention, it guides patients to local programs; gives physical therapists and trainers guidelines for working with specific conditions, and provides doctors with research data. Rimmer hopes by next month to put online exercise programs on the center’s Web site that trainers can call up and tailor to their particular clients’ conditions.

And although few fitness instructors have specialized training in dealing with people who are old and frail or who have debilitating conditions, programs are cropping up to provide them with special credentials, Clark said. Her organization certifies personal trainers in dealing with joint replacements, arthritis, osteoporosis, Parkinson’s, Alzheimer’s and other conditions.

Knopf, a professor at Foothill College in Los Altos, in Northern California, has spent 25 years teaching the disabled, and teaching others to make the proper modifications to work with them. “These programs must be individualized for the client,” he said. “The American way is to do wholesale fitness, and it doesn’t work.”

Researchers are trying to pinpoint what constitutes healthy exercise for people with special needs, so that, for example, someone with severe arthritis doesn’t become injured following the standard 30-minutes-a-day prescription for walking.

Exercise for these people sometimes focuses on helping them carry out basic daily activities. For some, that can be as simple as exercises they perform in a chair or on their bed.

“You can still make a difference in their ability to carry out day-to-day activities that everybody needs to do: walking, lifting small objects,” Clark said.

Community Programs Offer Specialized Classes

Some people can improve their fitness with something as simple as tuning into a nationally televised program, “Sit and Be Fit,” broadcast on more than 100 public television stations nationwide. The host, registered nurse Mary Ann Wilson, provides safe routines to improve strength, flexibility and coordination. Wilson also has developed specialized videotape routines for particular conditions.

For those who can maneuver outside the home, fitness professionals advise pursuing all local avenues. YMCAs, hospital outpatient exercise programs and community colleges often offer specialized exercise classes.

In addition, many disease support and education groups provide community-based programs. The Arthritis Foundation offers a water-based program at little or no cost.

And some branches of the American Parkinson’s Disease Assn. offer Parkinsonians Learning Lifelong Useful Skills, or PLLUS, a program of regular activity developed in Los Angeles by a couple of Parkinson’s patients, along with neurologists.

“If people can find the right help, the right program, they don’t have to live with this physical frailty,” said C. Jessie Jones, an exercise physiologist and co-director of the Center for Successful Aging at Cal State Fullerton. She works directly with disabled and chronically ill older adults to improve their balance and mobility while rebuilding their strength. She also has helped set up similar programs.

Even people with progressive disorders can benefit from physical activity. UCLA’s Cummings said one Parkinson’s patient in particular demonstrates just how much physical progress can be made--with the right accommodations.

Tichi Wilkerson Kassel, the former owner and publisher of the Hollywood Reporter, was diagnosed with the progressive, degenerative disorder in 1988.

To get her to exercise, her husband, Arthur Kassel, said he “started building what I believed would be the best state-of-the-art pool for a handicapped person.”

The result is a kind of backyard water park with a specially heated free-form pool and a Jacuzzi his wife can walk into from the pool. The pool has stainless-steel grab-bars for poolside stretching and stability, an overhead rope for hand-over-hand maneuvers and a 20-foot sloped entrance that gives his wife “an opportunity to develop a gait.”

On good days, “she can get into the pool on her own foot power,” holding rust-proof rails fashioned from bow rails used on yachts. On days when her body is more rigid, she can roll into the water in her submersible wheelchair.

“The most important thing you could ever do is empower somebody, to take charge of their own life and own movements,” Arthur Kassel said.

With her illness at an advanced stage, Tichi Kassel’s face sometimes becomes frozen and expressionless. But when she dunks her head in the warm pool water, “the Parkinson’s mask slips away,” and she smiles, her husband said recently as his wife demonstrated her progress to her neurologist.

“There’s no doubt you’re talking about several more years of survival” as a result of her water exercise, Cummings said.

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How to Get Moving

Exercise can be as simple as gentle lifts, bends and flexes or as vigorous as aerobic activity. Older persons and others with physical limitations can safely perform stretching, strengthening and flexibility exercises such as these below.

NECK ALIGNMENT

Position: Sit or stand erect, looking straight ahead. Touch chin with fingertips of one hand.

Movement: Pull chin away from hand, keeping chin level.

Result: This restores alignment and takes stress off the neck.

SHOULDER EXERCISE

Position: Seated, hold a towel around back of waistline, with palms facing forward.

Movement: Gently pull both ends of towel until you feel a mild stretch in front of both shoulders. Hold one or two seconds.

Result: This eases tightness in the front of the shoulders and promotes good posture.

CALF STRETCH

Position: Sit up straight with both feet flat on the floor.

Movement: Extend one leg forward, flexing the ankle. Imagine you are pulling the toes toward the knee. Alternate with each leg and repeat four times.

Result: This stretches the calf muscle, which helps avoid cramping in the lower leg.

Source: Mary Ann Wilson, “Sit and Be Fit”