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Physiotherapy and Older People

Original Editor - Bhanu Ramaswamy as part of the AGILE (Age-related Interest Group Linked to Education) Project.
Top Contributors - Bhanu Ramaswamy, Mahbubur Rahman, Admin, Kim Jackson, Lauren Lopez, Lucinda hampton, Shaimaa Eldib, Alexandra Stead, Vidya Acharya, Tolulope Adeniji, Evan Thomas, Candace Goh, Aminat Abolade and Janine van Dyk

Introduction

Geriatric medicine word cloud

Physiotherapists are key members of multidisciplinary teams supporting older adults to maintain or regain mobility, independence and participation, including those with falls, stroke, arthritis and living with frailty.[1]

There is strong evidence for the effectiveness of primary care and community-based falls prevention programmes for older people, such as the Otago Exercise Programme, which can reduce falls by around one-third in community-dwelling older adults when delivered under physiotherapy supervision.[2][3] International evidence also exists showing the benefit of exercise interventions for older people with frailty, which are primarily physiotherapy-led or physiotherapy-supervised, although the optimal programme design is not yet fully established.[4]

Physiotherapy is also a core component of the Comprehensive Geriatric Assessment (CGA), which has been shown to increase the likelihood of older people being alive and living in their own homes at up to 12 months after hospital admission, and to reduce the likelihood of institutionalisation.[5] A CGA approach is part of successful orthogeriatric care (combined orthopaedic and geriatric management, typically following hip fracture) and is increasingly used in perioperative surgical care for older people, where it has been shown to improve outcomes such as reduced postoperative delirium.[6] Alongside specialist elderly care wards, physiotherapists are also core members of the stroke unit Multidisciplinary Team, and organised inpatient stroke unit care is consistently associated with improved outcomes, including a greater likelihood of surviving, returning home and regaining independence.[7]

Guiding Principles

Physiotherapy for older people is underpinned by several core principles. Disability is generally regarded as resulting from a pathological process or injury, rather than from old age itself.[8] The effects of biological ageing reduce the efficiency of the body's systems, but throughout life, optimum function can be maintained by continuing to use these systems to their full capacity.[9] Physiotherapists have a key role in enabling older people to use their body's systems fully, in order to enhance mobility and independence; when neither improvement nor maintenance of functional mobility is a realistic goal, physiotherapists can instead help older people remain comfortable and free from pain. Prevention of future problems through health promotion is also an important part of this role.[10]

Physiotherapy Settings

Geriatric Care

Health and social care systems for older people vary considerably worldwide, and the WHO's Rehabilitation 2030 initiative highlights that access to physiotherapy remains inconsistent globally, with rehabilitation needs projected to rise sharply as populations age.[10] In the UK, several models of service delivery have been established to meet the needs of older people, most of which involve physiotherapy input.[1] Common settings include:

  • Health promotion and disability prevention programmes.[10]
  • Hospital settings, including acute general wards, specialised older persons' units, or dedicated rehabilitation wards.[1]
  • Outpatient ambulatory clinics or day assessment and rehabilitation units, where individuals typically receive input from more than one profession over the course of a day.[11]
Elder in day care unit

Community

Alongside hospital and outpatient care, physiotherapy is delivered extensively within community settings, ranging from short-term, admission-avoidance services to longer-term rehabilitation teams:[12]

  • Community physiotherapy in a person's own home or at a doctor's clinic, provided by either private physiotherapy companies or government-funded healthcare services.
  • Regional and local outreach services for specific conditions, such as monitoring services for neurological or respiratory conditions, with rapid response capability if a therapist detects a decline in a person's condition.
  • Intermediate care, jointly funded by health and social services and delivered by a multidisciplinary team, usually lasting up to six weeks. It aims to prevent hospital (re)admission and support safe discharge, and can take place in the person's own home or in beds set aside for rehabilitation at a residential care facility.
  • Community rehabilitation teams, which may support people for up to 12 weeks. These teams were historically funded to support early hospital discharge for people post-stroke, but now also support people with orthopaedic and general rehabilitation needs.
  • Physiotherapists working within mental health teams, who may be called upon for specialist advice.
  • Research institutes, where research into age-related conditions and issues is conducted.

Essential Skills for a Geriatric Physiotherapist

Older adult care is complex, often requiring knowledge across multiple specialties. Older adults commonly develop musculoskeletal, cardiovascular and neurological conditions.[8] There may be overlap between these categories, as older adults often present with multimorbidity.[13] Because of the effects of ageing on health status and disease presentation, physiotherapists working with older adults should be trained in musculoskeletal, neurological and cardiovascular assessment and management.[14] Essential skills for a physiotherapist specialising in geriatric care should therefore include sound knowledge of physiotherapy practice across these three areas, with a specific focus on the needs of older adults.

Assessment

Assessment and treatment planning for older people should follow relevant national protocols and guidance. The assessment of older people differs from that of younger people in that it must account for the physiological changes that occur with age.

There are several models of rehabilitation. The most universal and inclusive is the World Health Organization's (WHO) International Classification of Functioning, Disability and Health (ICF). The ICF offers a framework through which healthcare professionals can review multiple impairments and relate them to the relevant domains of an individual's life, guiding assessment, goal setting and treatment planning.

Permission granted by WHO. Source: Short version booklet of the International Classification of Functioning, Disability and Health (WHO 2001), page 26. Reference Number 92 4 154544 5
Permission granted by WHO. Source: Short version booklet of the International Classification of Functioning, Disability and Health (WHO 2001), page 26. Reference Number 92 4 154544 5

The ICF is valuable to clinicians because it can guide a thorough assessment of the older person, helping clinicians see how impairments affect activities of daily living and participation in societal roles in later life.[9] The ICF also considers the person in context, including environmental factors (physical location and societal attitudes) and personal factors (medication, social supports), which can act as either barriers or facilitators when planning appropriate interventions and support. Many hospitals in the UK also use the related International Classification of Diseases (ICD-10), a WHO classification system used to code patients' diagnoses on admission, which complements the ICF.[15]

Medical History

A thorough medical/surgical history and drug history are important, since:

  • Medications can significantly impact older adults and contribute to poor mobility and falls. See Medication and Older People.
  • An older person might not report a significant medical condition, such as an underlying cardiovascular condition.

Social History

Older adults often rely on formal or informal supports, such as family and friends, and a lack of such support is a recognised risk factor for poor outcomes after hospital discharge.[16] For example, a physiotherapist, together with other allied health professionals, may need to consider how to safely support an older person being discharged home alone who is unable to stand safely to cook a meal or walk to the shops for food.

The ICF can guide clinicians through assessment and act as a checklist to ensure all relevant history and assessment areas are covered.

Outcome Measures

Outcome measures allow physiotherapists to track meaningful change in an older person's function over time, and are particularly important in this population given the high prevalence of frailty,[4] multimorbidity[13] and falls risk.[2] Commonly used measures include the Berg Balance Scale and Functional Reach Test for balance, the Barthel Index and Elderly Mobility Scale for functional independence, and the Functional Independence Measure for broader rehabilitation outcomes. The choice of outcome measure should reflect the specific goals of treatment as well as the setting in which care is delivered, since physiotherapists, managers and purchasers, and the individual themselves may each be interested in different aspects of change.

Goal Setting

Goal setting is central to keeping physiotherapy person-centred and to coordinating treatment across a multidisciplinary team. Goals should be directed towards managing and improving a person's condition, rather than providing passive 'care', and are most effective when developed collaboratively with other team members, in both hospital and community settings, so that everyone involved understands and works towards the same outcomes.[17]

Goals may aim to improve an older person's function, or to maintain their current level of function and prevent decline. This requires the physiotherapist to understand what constitutes an acceptable 'norm' for a person's age group, such as expected age-related changes in gait and posture. At times, there may be tension between a person's own goals and the therapist's view of what is safe; in these situations, the physiotherapist's role is to highlight and minimise risk where possible, rather than to prevent the person from functioning altogether.

Treatment

Older persons exercise class

Physiotherapy assessment and treatment tend to focus on the physical aspects of a person's condition.[18] For older adults, physical activities of daily living are an important starting point for treatment, and intervention should include (re)assessment of a person's abilities and difficulties in performing functional tasks.[18] This can include, for example, transfers on and off a chair or bed, and general mobility.

Functional Rehabilitation

Many physiotherapy techniques used with older people are similar to those used with other age groups, adapted to the individual's needs; however, mechanical changes to a person's skeleton may require modification of treatment positioning,[19] and extra time is often needed for learning and practising skills and exercises.[20]

Exercise Prescription and Dosage

Exercise is a core component of physiotherapy for older people, particularly for falls prevention and the management of frailty.[2][3][4] Individually prescribed, multicomponent strength and balance programmes, such as the Otago Exercise Programme, have been shown to reduce falls by around one-third in community-dwelling older adults when delivered with appropriate dosage and progression.[2][3] Programmes generally combine progressive resistance training, balance training and functional exercise, delivered at a frequency and intensity sufficient to produce a training effect, typically at least twice weekly for a minimum of several months, with exercises progressed as strength and confidence improve.[3] Exercise interventions have also demonstrated benefit for older people living with frailty.[4]

Balance Training

Balance Training should be tailored to an individual's level of risk and ability, progressing from static to dynamic balance tasks and incorporating reactive balance strategies where appropriate.[21]

Pain Management

Pain is common in older people and is frequently under-reported or under-recognised, particularly in those with cognitive impairment.[22] Assessment should include self-report where possible, using tools appropriate to the individual's cognitive status, and management should combine pharmacological and non-pharmacological approaches, including physiotherapy-led exercise and manual therapy.[23] See Chronic Pain for further detail.

Treatment Modifications for Older Adults

Extra care must be taken with some treatment techniques, and more time should be allowed for learning and practising skills and exercises. For example, with an acute sprain, history taking would be no different, but treatment planning must account for more of the person's past medical history and pre-injury status. Historically, treatment for acute soft-tissue injury focused on rest, ice, compression and elevation; however, current sports-medicine guidance has moved away from RICE towards the PEACE & LOVE approach, which cautions against prolonged icing and passive rest in favour of protection, optimism, and a gradual return to activity.[24] When considering ice, compression or elevation for an older person with an already oedematous ankle, the therapist should also assess the condition of the skin to allow for safe use of ice or compression,[25] and should check hamstring length. Sufficient hamstring length confirms whether the person can sit comfortably for the duration of treatment with their hips flexed to 90 degrees or more.

Discharge Planning

Discharge Planning requires careful consideration and is an important element in preventing adverse events after discharge. In a prospective cohort study, 19% of patients discharged from a general medical service experienced an adverse event within around three weeks of discharge, most commonly related to medication.[26] Separately, a systematic review reported a median of 27% of hospital readmissions as avoidable, with some studies finding this as high as almost 80%.[27]

Summary

Physiotherapy has a central role in supporting older people to stay independent, manage frailty and multiple long-term conditions, and recover from events such as stroke, falls and surgery. Good practice starts with a thorough assessment guided by the ICF, moves through person-centred goal setting that balances safety with the person's own priorities, and includes treatment approaches adapted to the physical changes that come with ageing. Careful discharge planning then helps reduce the risk of readmission. As the population ages worldwide, demand for physiotherapy for older people, in hospitals, in the community and internationally, will only continue to grow.

References

  1. ↑ 1.0 1.1 1.2 British Geriatrics Society. Physiotherapy and older people. London: BGS; 2023.
  2. ↑ 2.0 2.1 2.2 2.3 Montero-Odasso M, van der Velde N, Martin FC, Petrovic M, Tan MP, Ryg J, et al. World guidelines for falls prevention and management for older adults: A global initiative. Age and Ageing [Internet]. 2022 [cited 2026 Sept 5];51(9).
  3. ↑ 3.0 3.1 3.2 3.3 Sherrington C, Fairhall NJ, Wallbank GK, Tiedemann A, Michaleff ZA, Howard K, et al. Exercise for preventing falls in older people living in the community. Cochrane Database of Systematic Reviews [Internet]. 2020 Jan 31 [cited 2026 Sept 5];1(1):CD012424.
  4. ↑ 4.0 4.1 4.2 4.3 de Labra C, Guimaraes-Pinheiro C, Maseda A, Lorenzo T, Millán-Calenti JC. Effects of Physical Exercise Interventions in Frail Older adults: a Systematic Review of Randomized Controlled Trials. BMC Geriatrics [Internet]. 2015 Dec [cited 2026 Sept 5];15(1).
  5. ↑ Ellis G, Gardner M, Tsiachristas A, Langhorne P, Burke O, Harwood RH, Conroy SP, Kircher T, Somme D, Saltvedt I, Wald H. Comprehensive geriatric assessment for older adults admitted to hospital. Cochrane Database of Systematic Reviews. 2017(9).
  6. ↑ Eamer G, Taheri A, Chen SS, Daviduck Q, Chambers T, Shi X, Khadaroo RG. Comprehensive geriatric assessment for older people admitted to a surgical service. Cochrane Database of Systematic Reviews. 2018(1).
  7. ↑ Langhorne P, Ramachandra S; Stroke Unit Trialists' Collaboration. Organised inpatient (stroke unit) care for stroke: network meta-analysis. Cochrane Database of Systematic Reviews. 2020;4(4):CD000197.
  8. ↑ 8.0 8.1 Pasquetti P, Apicella L, Mangone G. Pathogenesis and treatment of falls in elderly. Clinical Cases in Mineral and Bone Metabolism. 2014 Sep;11(3):222.
  9. ↑ 9.0 9.1 Izaks G, Westendorp R. Ill or just old? Towards a conceptual framework of the relation between ageing and disease. BMC Geriatrics. 2003;3(7).
  10. ↑ 10.0 10.1 10.2 World Health Organization. Rehabilitation 2030: A Call for Action. Geneva: WHO; 2017.
  11. ↑ Brown L, Forster A, Young J, Crocker T, Benham A, Langhorne P; Day Hospital Group. Medical day hospital care for older people versus alternative forms of care. Cochrane Database of Systematic Reviews. 2015;2015(6):CD001730.
  12. ↑ National Institute for Health and Care Excellence. Intermediate care including reablement. NICE guideline [NG74]. London: NICE; 2017.
  13. ↑ 13.0 13.1 Barnett K, Mercer SW, Norbury M, Watt G, Wyke S, Guthrie B. Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study. The Lancet. 2012;380(9836):37-43.
  14. ↑ Perissinotto CM, Ritchie C. Atypical Presentations of Illness in Older Adults. In: Williams BA, Chang A, Ahalt C, Chen H, Conant R, Landefeld C, Ritchie C, Yukawa M, editors. Current Diagnosis & Treatment: Geriatrics. 2nd ed. New York: McGraw-Hill Education; 2014.
  15. ↑ World Health Organization. International Statistical Classification of Diseases and Related Health Problems, 10th Revision. Geneva: WHO; 2019.
  16. ↑ Provencher V, Clemson L, Wales K, Cameron ID, Gitlin LN, Grenier A, et al. Supporting at-risk older adults transitioning from hospital to home: who benefits from an evidence-based patient-centered discharge planning intervention? Post-hoc analysis from a randomized trial. BMC Geriatrics [Internet]. 2020 Mar 2 [cited 2026 Sept 5];20(1).
  17. ↑ Squires A, Hastings M, editors. Rehabilitation of Older People: A Handbook for the Interdisciplinary Team. 3rd ed. Cheltenham: Nelson Thornes; 2000.
  18. ↑ 18.0 18.1 Jahan AM. Insight into functional decline assessment in older adults: A physiotherapist's perspective. Archives of Gerontology and Geriatrics Plus. 2024;1(4):100048.
  19. ↑ Katzman WB, Wanek L, Shepherd JA, Sellmeyer DE. Age-related hyperkyphosis: its causes, consequences, and management. Journal of Orthopaedic and Sports Physical Therapy. 2010;40(6):352-360.
  20. ↑ Voelcker-Rehage C. Motor-skill learning in older adults — a review of studies on age-related differences. European Review of Aging and Physical Activity. 2008;5:5-16.
  21. ↑ Lesinski M, Hortobágyi T, Muehlbauer T, Gollhofer A, Granacher U. Effects of Balance Training on Balance Performance in Healthy Older Adults: A Systematic Review and Meta-analysis. Sports Medicine. 2015;45(12):1721-1738.
  22. ↑ Cravello L, Di Santo S, Varrassi G, Benincasa D, Marchettini P, de Tommaso M, Shofany J, Assogna F, Perotta D, Palmer K, Paladini A, di Iulio F, Caltagirone C. Chronic pain in the elderly with cognitive decline: a narrative review. Pain and Therapy. 2019;8(1):53-65.
  23. ↑ Abdulla A, Adams N, Bone M, Elliott A, Gaffin J, Jones D, Knaggs R, Martin D, Sampson L, Schofield P. Evidence-based clinical practice guidelines on the management of pain in older people: executive summary. British Journal of Pain. 2013;7(3):152-154.
  24. ↑ Dubois B, Esculier J-F. Soft-tissue injuries simply need PEACE and LOVE. British Journal of Sports Medicine. 2020;54(2):72-73.
  25. ↑ Chesterton LS, Foster NE, Ross L. Skin temperature response to cryotherapy. Archives of Physical Medicine and Rehabilitation. 2002;83(4):543-549.
  26. ↑ Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. The incidence and severity of adverse events affecting patients after discharge from the hospital. Annals of Internal Medicine. 2003;138(3):161-7.
  27. ↑ van Walraven C, Bennett C, Jennings A, Austin PC, Forster AJ. Proportion of hospital readmissions deemed avoidable: a systematic review. CMAJ. 2011;183(7):E391-E402.
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