| Abstract|| |
Geriatric orthopedic problems poses different challenges in their management. Conventional treatment methods like drugs, physiotherapy and surgeries are inadequate. A Geriatric orthopedic patient suffers as a whole and not in isolation. This article highlights the importance of managing geriatric orthopedic patients as a whole and outlines the various steps of wholistic management.
Keywords: Geriatric orthopedics, rehab therapy, reversal therapy, WHO, Wholistic therapy
|How to cite this article:|
Ebnezar J, Bali Y, John R. Wholistic orthopedics: Is this the right way to treat geriatric orthopedic patients?. Int J Yoga 2017;10:40-3
|How to cite this URL:|
Ebnezar J, Bali Y, John R. Wholistic orthopedics: Is this the right way to treat geriatric orthopedic patients?. Int J Yoga [serial online] 2017 [cited 2017 May 27];10:40-3. Available from: http://www.ijoy.org.in/text.asp?2017/10/1/40/194560
| Introduction|| |
Life is a gift from God and almost everyone wants to live long. Our life span is steadily increasing, from 47 years in 1900 to 72 years in 2000 and >80 years in 2015,  geriatric orthopedic problems (GOPs) have assumed great significance in the recent times across the globe and India.
The term geriatrics was coined in 1909 by Ignatz Nascher (1863-1944) in "New York Medical." The Term Geriatrics was coined in1909 by Ignatz L.  Nascher (18631944) In England, from Gk. geras "old age" (from PIE base *gere "to grow old;" cf. Skt. jarati "makesfrail, causes to age") + iatrikos "of a physician," from iatros, related to iasthai "heal, treat," of uncertain origin.  Geriatric population forms 8% of our population today. In a few years, 80 will be the new 40 and people will live for centuries.  Elderly patients are victims of multiple diseases and fragility fractures pose different set of challenges. Moreover, further what are we going to do if the patient has side effects for drugs, is unwilling for surgery, cannot afford surgery, not fit for surgery? Do we have answers for the patients like these?
Extensive Research in Yoga and Orthopedics included a largest randomized controlled trial on osteoarthritis (OA) knees over 250 patients. The research then extended to neck pain, osteoporosis, low backache, and even fractures. ,, Research on role of yoga in fracture treatment was published by the Journal of Complementary and Alternative Medicine. 
| From Holistic to Wholistic|| |
During the treatment, this author found that elderly patients were not just suffering from pain, they were full of fear, anxiety, mental and emotional turmoil, financial crisis, had comusculoskeletal conditions, comorbidities, already were taking many drugs and were victims of failed treatment. Hence, most of them suffered as a whole, the first letter of whole is the WHO. Moreover, the WHO has defined health as "a state of complete physical, mental, social, and spiritual well-being and not just the absence of a disease or infirmity."  Based on this, the name in the author's practice is changed from "holistic" to "wholistic."
The primary aim of orthopedic treatment in geriatrics is return of function and independent life. Prevention of further deterioration and recurrence is vital. Can these be achieved with the conventional approach? We need a more broad-based integrated approach in GOP a change from unidimensional approach (adults) to multidimensional approach (geriatrics). Merely trying to fix an ortho problem with drugs or surgery like in young is an invitation to disaster.
The nine peculiar GOPs that challenges the conventional treatment methods are comorbid conditions, comusculoskeletal, cophysical, comental, cosocial, cofamily, cofinancial, coagency problems, and stress that make the patient suffers as a whole. Does the answer lie in going wholistic?
Limitations of treating geriatric patients with mainly drugs?
Drugs damage the stomach and the gastrointestinal tract and could cause ulcers, , bleeding; it could damage the kidneys  and liver too.
Surgery - What are the Role, problems, and limitations in surgery?
Surgical procedures are very effective in severe cases or when other treatment methods fail.
Is Wholistic orthopedics relevant to geriatric orthopedics and orthopedic practice in today's times?
Look at the toxicity profile in therapeutic OA modalities [Figure 1]. It clearly shows that drugs and surgery are high on toxicity, education, and exercises are low on toxicity. They are the least harmful treatment options and can be advised to all the stages of arthritis in almost everyone.
|Figure 1: Toxicity profile of the treatment modalities based on expert opinion (23 experts)|
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[Figure 1] shows toxicity profile of treatment modalities based on expert opinion (of 23 experts).
How to make conventional treatment methods more effective in geriatric age group?
We have understood the concept of WHOLE - about wholistic orthopedics. Who is a human being? Human = body, being = soul (energy). We are not just skeletons and we have 5 layers of existence. A geriatric patient suffers as a whole involving physical, mental, social, and emotional and spiritual aspects. We have very effective conventional treatment methods but not complete, what is the missing link? Hence, we need something safe and different.
Is the missing link - The "human therapy"?
When a senior citizen comes for treatment, we need to talk to them with kindness, listen to their problems with empathy, give them a loving touch, hug, and then execute the treatment plans. Human therapy such as love, kindness, understanding, patience, empathy, will make the treatment effective and it is a win-win situation. I have no better word to describe these, hence coined the term "human therapy."
Wholistic orthopedics is a simple human being and not just skeleton-based approach. This begins with the talk and may end up with surgery. It is a 12 modalities approach [Figure 2]: Now let us analyze each step in greater detail:
|Figure 2: The 12-step wholistic treatment for geriatric orthopedic problems|
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[Figure 2] shows the 12-step wholistic treatment for GOPs.
Substituting empathy for sympathy and consists of the following options, talk, listen, touch, hug, and music therapies.
The tongue is mightier than a sword. Talk smoothly, caringly, and lovingly. Everything is in the talk, patients relate to you better and a sweet talking doctor is more popular Beck's talk cognitive therapy is very successful in applications in chronic pain in elderly patients (1988). 
This is very effective in GOP. Why? Most of the patients just want their doctors to listen, there are lots of things going on in their mind, and they want their doctors to just listen. Listening creates a feeling of goodwill in intimate and professional relationships. The more you listen without judgment, the more freedom speakers have to find their own solutions to problems. 
Krieger et al. , developed and standardized the technique in the 1970s. Therapeutic touch is based on balancing of the human energy systems. Illness is an imbalance in an individual's energy field. Clearing or balancing the energy field promotes health and all humans have natural abilities to heal and enhance the healing in others. Early therapeutic touch studies reported by Heidt  showed efficacy in muscle relaxation, stress, and anxiety reduction. Later studies identify physiological effects (pulse amplitude, blood pressure, pulse, and temperature) as well as subjective measures, such as stress, time perception, and self-assessment of health. Healing touch is a collection of techniques developed and compiled by Janet Mentgen in the early 1980s. ,
Do you remember Munnabhai MBBS,  Sanjay Dutt's famous Jappi? Research shows proper deep hugs, where the hearts are pressing together, the nurturing touch of a hug builds trust and a sense of safety. This helps with open and honest communication. Hugs can instantly boost oxytocin levels,  which heal feelings of loneliness, isolation, and anger; holding a hug for an extended time lifts one's serotonin levels, elevating mood, and creating happiness. There is a saying by Satir,  a respected family therapist: A formula of 4-8-12 is recommended: We need 4 hugs a day for survival, 8 hugs a day for maintenance, and 12 hugs a day for growth.
These "human therapies" help develop a rapport, soothes the nerves, allays tension and fear, compliance improves, it makes them more receptive, treatment becomes more effective, as it helps develop a healthy bond, reduces stress. Litigation rate may also drop considerably.
For whole body diagnosis - appropriate pro formas are filled up by questioning the patients and their relatives and not just fill up investigations forms such as computed tomography scan and magnetic resonance imaging.
Judicious drug therapy
We should avoid giving drugs such as painkillers, muscle relaxants, and other drugs indiscriminately as it can cause side effects and toxicity and practice judicious prescription of appropriate drugs.
It is a noninvasive treatment modality. It helps in pain relief, release of spasm, and improves function.
Exercises form the mainstay of the treatment in most of the musculoskeletal problems in old age. What would be the best choices? Body-based exercises or mind-body exercises such as Yoga? The latter has a distinct advantage in managing these chronic patients. If you make a choice of mind-body exercises,  it treats both the diseases of the old age and stress. There are two options such as the Chinese Tai Chi,  and our own yoga.
Integrated approach of yoga therapy  designed and developed by S-VYASA, Bengaluru, is an excellent scientific research-based combination of tried and tested yoga practices that can be very effective in treating the common GOPs without the fear of any side effect or complication. It helps loosen and strengthen the entire body; asana improves posture, gait, balance, and coordination. Overall benefits: It improves overall health, helps in mind and emotional relaxation, and improves comusculoskeletal conditions, comorbidities, and comental conditions.
Relaxation therapies are very important for mental and emotional well-being of geriatric patients.
Reversal therapy concept is very important to educate the patients to reverse all the disease nonmodifiable risk factors such as sedentary lifestyles, improper postures, improper dietary habits, lack of exercises, alcohol, smoking, drugs, and stress, which brought or aggravated the disease.
Education therapy includes the awareness of proper postural practices, understanding old age, and alterations of daily living by lectures and counseling. The advantage of all these would be that effect of the disease is reduced and it has a greater preventive role of further progression of the disease.
Diet therapy is very important that patients need to be told about the importance of healthy diet.
Supportive therapy such as proper use of back belts, collars, knee caps, etc.
Rehab programs - substitute conservative treatment with rehabilitation programs.
Surgery when all the approaches fail or if the conditions are severe then an indication for surgery arises and can then work wonders for the patient. 
| Conclusion|| |
In GOPs, we need to change from the restrictive orthopedics to a more wholistic orthopedic approach of healing at the body, mind, and emotional levels.  The American Association of Orthopedic Surgeon's (AAOS) in their recent 2013 guidelines  for nonarthroplasty management of OA knees has incorporated all three studies by this author ,, on the role of yoga therapy in the treatment of OA knees and have given a strong recommendation for this form of wholistic treatment of OA knees.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
World Population Prospects: Revision United Nation. ESA/P/WP. 193, 24 February, 2005. Department of Economic and Social Affairs Population Division; 2004.
Clarfield AM. Dr. Ignatz Nascher and the birth of geriatrics. CMAJ 1990;143:944-5, 948.
Times of India, Bangalore Edition. 19 th
April, Sunday Times; 2014.
Altman RD, Hochberg MC, Moskowitz RW. Recommendations for the medical management of osteoarthritis of the hip and knee: New OA practice management guidelines from the ACR. Arthritis Rheum 2000;43:1905-15.
Ebnezar J, Nagarathna R, Yogitha B, Nagendra HR. Effects of an integrated approach of hatha yoga therapy on functional disability, pain, and flexibility in osteoarthritis of the knee joint: A randomized controlled study. J Altern Complement Med 2012;18:463-72.
Ebnezar J, Nagarathna R, Bali Y, Nagendra HR. Effect of an integrated approach of yoga therapy on quality of life in osteoarthritis of the knee joint: A randomized control study. Int J Yoga 2011;4:55-63.
Ebnezar J, Nagarathna R, Yogitha B, Nagendra HR. Effect of integrated yoga therapy on pain, morning stiffness and anxiety in osteoarthritis of the knee joint: A randomized control study. Int J Yoga 2012;5:28-36.
Oswal P, Nagarathna R, Ebnezar J, Nagendra HR. The effect of add-on yogic prana energization technique (YPET) on healing of fresh fractures: A randomized control study. J Altern Complement Med 2011;17:1-6.
Dolfman ML. The concept of health: An historic and analytic examination. J Sch Health 1973;43:491-7.
Griffin MR. Epidemiology of nonsteroidal anti-inflammatory drug-associated gastrointestinal injury. Am J Med 1998;104:23S-9S.
Gabriel SE, Jaakkimainen L, Bombardier C. Risk for serious gastrointestinal complications related to use of nonsteroidal anti-inflammatory drugs. A meta-analysis. Ann Intern Med 1991;115:787-96.
Garella S, Matarese RA. Renal effects of prostaglandins and clinical adverse effects of nonsteroidal anti-inflammatory agents. Medicine (Baltimore) 1984;63:165-81.
Beck AT, Epstein N, Harrison R. Cognitions, attitudes and personality dimensions in depression. Br J Cogn Psychother 1983;1:1-16.
Steil, Lyman K, Bommelje RK. Listening Leaders: The Ten Golden Rules to Listen, Lead and Succeed. Edina, MN: Beaver's Pond; 2004.
Heidt P. Effect of therapeutic touch on anxiety level of hospitalized patients. Nurs Res 1981;30:32-7.
Krieger D. Dolores Krieger, RN, PhD healing with therapeutic touch. Interview by Bonnie Horrigan. Altern Ther Health Med 1998;4:86-92.
Mentgen J. RN, BSN (1938-2005). Healing Touch International, Inc.; 1996.
Munnabhai. A Hindi movie made by Vidhu Vinod Chopra and had Released in 2003.
Satir V. Self Esteem. Berkeley, Calif: Celestial Arts; 2001.
Luskin FM, Newell KA, Griffith M, Holmes M, Telles S, DiNucci E, et al.
A review of mind/body therapies in the treatment of musculoskeletal disorders with implications for the elderly. Altern Ther Health Med 2000;6:46-56.
Wang C, Schmid CH, Hibberd PL, Kalish R, Roubenoff R, Rones R, et al.
Tai Chi for treating knee osteoarthritis: Designing a long-term follow up randomized controlled trial. BMC Musculoskelet Disord 2008;9:108.
Nagarathna R, Nagendra HR. Yoga for the Promotion of Positive Health. Bangalore: Swami Vivekānanda Yoga Prakashana; 2000.
Buckwalter JA, Lohmander S. Operative treatment of osteoarthrosis. Current practice and future development. J Bone Joint Surg Am 1994;76:1405-18.
Van Dijk GM, Veenhof C, Schellevis F. Comorbidity, limitations in activities and pain in patients with osteoarthritis of the hip or knee. BMC Musculoskelet Disord 2008;9:95.
Ebnezar J, Nagarathna R. Bali Y, Nagendra HR, et al
. Non-arthroplasty treatment of osteoarthritis of the knee. Treatment of osteoarthritis of the knee. 2 nd
ed. AAOS; 2013.
Department of Orthopedics, Ebnezar Orthopedic Center, Parimala Hospital, Bilekahalli, BG Road, Bengaluru - 560 076, Karnataka
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2]