Role of physiotherapy in the elderly

Objectives of physiotherapy in the older patient (Kane's): relieve pain; evaluate, maintain and improve joint range of motion; evaluate and improve strength, endurance, motor skills and coordination; evaluate and improve gait and stability; and assess the need for, and teach the use of, assistive devices for ambulation – wheelchairs, walkers and canes. Pathy's frames the same role as enhancing cardiorespiratory, neuromuscular and locomotor function.

Exercise modalities: active exercise (isometric and isotonic), passive exercise for the immobile or paralysed limb, and structured sitting exercise programmes for those who cannot stand.

Physical modalities: heat – hot packs, paraffin wax, diathermy; ultrasound; hydrotherapy; and transcutaneous electrical nerve stimulation (TENS) for pain. Note that hydrotherapy improves self-confidence but has not been shown to produce measurable functional improvement in arthritic joints.

Falls, gait and balance: lower-extremity strength training, balance training including tai chi, gait retraining, properly fitted footwear, and habituation exercises for benign paroxysmal positional vertigo. Physiotherapy is one of the named treatments for gait and balance disorders, muscle weakness and deconditioning in the falls algorithm.

Musculoskeletal disease: daily range-of-motion exercise is particularly important for restoring function in arthritic joints, though compliance is poor at all ages – group activity adds a social component and improves compliance. Age-related stiffening of joints and soft tissues is reversible: exercise increases joint flexibility and improves the strength, size and resilience of cartilage, ligaments and muscle.

Prevention of the complications of immobility: chest physiotherapy and breathing exercises, upright positioning to prevent atelectasis and aspiration, positioning and proper handling to prevent contractures and shoulder subluxation in flaccid hemiplegia, and mobilisation to prevent DVT and pressure injuries. Preoperative training in cough and lung expansion techniques, with chest physiotherapy for those at pulmonary risk, is part of standard anaesthetic preparation of the elderly.

Neurological rehabilitation: even severely affected stroke patients achieve meaningful functional gains with early rehabilitation, and immobility and its complications can almost always be prevented or minimised. Treadmill training has repeatedly shown significant benefit for gait and balance in stroke survivors; robot-assisted motor training has shown some positive benefit. Ongoing exercise after the acute phase maintains function, preserves quality of life and helps prevent recurrent stroke.

Pulmonary and cardiac rehabilitation: in COPD, pulmonary rehabilitation reduces dyspnoea and fatigue, increases exercise capacity, enhances patient control of the disease, improves quality of life and may prevent hospitalisation. Benefits are similar in all adults including the "old old", and are greatest in the most impaired patients. Patients with asthma and interstitial disease benefit too. Even those hypoxic at rest or desaturating on exertion can be trained safely with supplemental oxygen.

Dementia and frailty: physical activity should be at moderate intensity for 30 minutes five times a week, or vigorous intensity for 25 minutes three times a week. Walking combined with strength, balance and flexibility exercise slows functional decline, increases gait speed, improves mood and sleep and reduces agitation. Compliance – more than cognitive status – is the limiting factor, so programmes must be enjoyable, individualised, accessible, and delivered with conversation or music, with staff communicating with the resident during the session.

Safety and setting: current guidance no longer recommends routine stress testing before starting physical activity; low-intensity activity can be safely initiated in asymptomatic sedentary older people regardless of recent medical evaluation, because sedentary behaviour creates more risk than moderate physical activity. Physiotherapy may be delivered in acute hospital, rehabilitation unit, skilled nursing facility, outpatient clinic or at home, individually or in groups depending on preference, cognition and motivation. Latest Updates (2023–present) — three key points

WHO physical activity guidance for adults aged 65 and over is now the reference prescription: 150–300 minutes of moderate aerobic activity per week, muscle-strengthening on at least 2 days, and – specifically for older adults – multicomponent activity emphasising balance and strength on at least 3 days per week to prevent falls and functional decline. "Every move counts"; some activity is better than none, and sedentary time should be limited.

In-hospital exercise reverses the functional decline of acute admission. The Martínez-Velilla multicomponent exercise trial (JAMA Internal Medicine 2019) remains the anchor; 2024–25 evidence extends it – a 2025 European Geriatric Medicine meta-analysis supports progressive mobilisation in hospitalised people with dementia, and service evaluations show functional resistance training on medical wards produces significant gains in grip strength, 30-second sit-to-stand and DEMMI scores.

Tele-rehabilitation and technology-assisted programmes are now evidence-supported for post-discharge deconditioning (smartphone-delivered resistance and balance programmes for patients on physiotherapy waiting lists) and for delivering Otago-based fall-prevention programmes in early geriatric rehabilitation using digital trainers with real-time correction.

The five physiotherapy objectives: relieve pain, improve range of motion, improve strength and endurance, improve gait and stability, and prescribe and teach assistive devices.

TENS, ultrasound, paraffin wax, diathermy, hot packs and hydrotherapy are the classic physical modalities.

Hydrotherapy improves self-confidence but not measurable joint function.

Treadmill training repeatedly improves gait and balance after stroke.

Pulmonary rehabilitation benefits are greatest in the most impaired patients, including the old old.

Age-related joint stiffening is reversible with exercise.

Group exercise improves compliance by adding a social component.

Routine stress testing is not required before starting low-intensity activity in asymptomatic older adults.

In dementia, compliance limits exercise programmes more than cognitive status does.

WHO 65+ prescription: 150–300 min moderate activity weekly, strengthening twice weekly, balance work three times weekly.