Multiple Body System Analysis Across the Lifespan

Original Editor - Ewa Jaraczewska based on the course by Eena Kapoor

Top Contributors - Ewa Jaraczewska and Jess Bell  

Introduction

Throughout the lifespan, the body experiences many changes in its cells, tissues, and organs, which can impact the functioning of all body systems. Everyone ages differently, and healthcare providers must be able to recognise these differences. This article explores multi-system characteristics, impairments, and interventions for children, adolescents, adults, and older adults.

Musculoskeletal System

A full musculoskeletal examination should be performed to assess the musculoskeletal system. Functional tests are an important part of this assessment.

The functional capacity of the musculoskeletal system should be assessed within the context of a person's school, play, work, daily activities, and sports. Because functional tests vary in terms of their reliability and validity, using a combination of a questionnaire and a functional test appears to be the most effective means to evaluate the functional capacity of the musculoskeletal system. The following questionnaires are recommended:

• Oswestry Disability Index
• Pain Disability Index
• Roland-Morris Disability Questionnaire
• Upper Extremity Functional Scale

Table 1 provides examples of functional tests that can be used in the musculoskeletal system assessment for children/adolescents, adults and older adults. It also identifies conditions and changes that can occur in the system across the lifespan.

Table 1. Functional Tests for the Musculoskeletal System Assessment

	Children/Adolescents	Adults	Older Adults
Muscle strength (functional assessment to include sit-to-stand and stairs)	Maximal volitional muscular force, contractile velocity and muscular power are lower than in adults. Children recover faster than adults from high-intensity, short-term exercise. The 1-minute sit-to-stand test (1MSTST) can be used to quantify exercise capacity. It measures how many times per minute an individual can stand up and sit on a chair standardised for height. In children aged 5-16 years, the median number of repetitions is 51-65. The Stair Climb Test (SCT) can be performed in different ways, depending on the population. The Four Stair Climb Test assesses motion capability in paediatric patients. This test has been described as follows: participants stand with both feet on the lower plateau of the stairwell and are given the following instructions: climb the four stairs as quickly as possible without running stand still on the upper plateau use the handrail if necessary The step-down manoeuvre is performed accordingly. Other protocols ask patients to go up and down four flights of stairs as quickly as they can to assess maximal exercise levels.	1MSTST: norm values range from 8.1 in individuals with stroke to 24 in individuals with advanced lung disease or 50 in healthy adult males.	1MSTST in healthy older men and women aged 75-79 years ranges from 22-37. Difficulty climbing stairs has been reported as a marker of functional decline that can lead to loss of independence. Older adults often report difficulty with stair climbing, and it is reported as one of the top five most difficult tasks to perform. Assessing a person's ability to climb stairs can provide information on hip and knee strength and stability. "The use of stair-climbing speed as an assessment tool should include both stair ascent and descent because differences in these speeds seem to be indicators of stair-climbing ability".
Flexibility / range of motion (spinal and chest wall mobility)	Chest wall mobility: Age 3 years through to adulthood: Chest wall mobility measurements for tidal volume excursion: 3rd rib site: size increases by approximately 2/8th (e.g. if it is initially 1 inch, it will increase to 1.25 inches). xiphoid site: approximately 3/8th. 1/2 distance site: 4/8th. Paediatric: 3rd rib site: approximately 1/8th. xiphoid site: approximately 2/8th. 1/2 distance site: 3/8th. Chest wall measurement for vital capacity: From 1-1/2 inches to 4 inches. Become larger as the measurement moves lower on the chest wall. Variable due to chest size. Spinal mobility: Assessing over-lengthened vs tight muscle. Lumbar spine mobility is greater in children than in adults. Caution must be applied during visual estimation of spine position as intra- and inter-rater reliability of a visual assessment is poor. Muscle weakness, abnormal positioning, and abnormal movement patterns may lead to abnormal spinal mobility.	Chest wall mobility: Chest wall mobility measurements for tidal volume excursion are the same as for children aged 3 years and older. Chest wall measurements for vital capacity are the same as for children aged 3 years and older. Spinal mobility: Measured in standing using the inclinometer technique: Lumbar flexion: the difference between thoracolumbar flexion and pelvic flexion. Lumbar extension: arching the trunk backwards. Right and left side-bending: a composite value of average side-bending.	Chest wall mobility: Chest wall mobility measurements for tidal volume excursion are the same as for children aged 3 years and older. Chest wall measurements for vital capacity are the same as for children aged 3 years and older. Spinal mobility: Measurement as for adults. In older adults, the most significant reduction in range of motion (ROM) is observed in lumbar extension. This is attributed to weakened abdominal and back muscles, hamstring tightness, or the individual's apprehension about balance loss during testing.
Pain	Children are not always able to indicate the location of their pain. Children aged between three and seven years can articulate the intensity of pain.	The Functional Pain Scale (FPS) can be used to objectively assess pain and its impact on sleep, the ability to complete activities of daily living (ADLs), and concentration.	The Functional Pain Scale is "an effective way to assess pain in the elderly and has proven helpful in identifying changes in pain".
Bone mineral density	Low bone mineral density (BMD) in early childhood increases a child's risk for fractures. Interventions, such as physical activity and calcium and vitamin D intake, help to improve BMD in older children.	Calcium, vitamin D, and BMD deficiencies are common in adults with coeliac disease. Patients with chronic obstructive pulmonary diseases and who are on long-term corticosteroids are more prone to decreased BMD. Patients with haemophilia or other bleeding disorders and patients who are on long-term anticoagulation present with a higher incidence of decreased BMD.	BMD decreases with age. Osteopenia often progresses to osteoporosis. Strength training can stimulate hypertrophy and increase muscle strength to counteract the loss of muscle mass.
Core stability	Core stability is a dynamic control of trunk pressures to optimise postural stability (balance). Breathing mechanics (e.g. the role of the diaphragm) are linked to postural control through multi-system interactions. Core stability extends from the vocal folds to the pelvic floor on the bottom.	Same as in children/adolescents.	Same as in children/adolescents.

Neurological System

"Neurons that fire together, wire together."

"Each time we practise that certain type of movement or certain type of action, we are laying down those pathways in our brain." -- Eena Kapoor

A neurological assessment includes many elements. For a detailed discussion of how to screen the neurological system, please see: Neurological Screen. This section discusses key functional tests that can be included in a neurological system assessment.

It is important to consider the following components in a neurological systems assessment:

• proprioception
  • ability to determine a body segment's position and movement in space
• vestibular system
  • ability to coordinate movement with balance (static and dynamic)
  • contributes to spatial orientation, postural control, and gaze stabilisation
• interoception
  • ability to detect/perceive internal body states, including heart rate, respiration, hunger, and digestion
  • our perception of internal body signals influences our emotions, decision-making, and sense of self
  • please watch the following optional video if you want to learn more about interoception

Table 2 provides examples of functional tests that can be part of the neurological system assessment for children/adolescents, adults and older adults. It also identifies conditions and changes that occur in the neurological system across the lifespan.

Table 2. Functional Tests for the Neurological System Assessment

	Children/Adolescents	Adults	Older Adults
Proprioception	Difficulties with motor coordination and planning may be linked to proprioception issues. Studies link poor proprioception to difficulties with handwriting. Poor proprioception can occur in conditions such as cerebral palsy, developmental coordination disorder, autism spectrum disorder, and in children with joint hypermobility. Indirect assessments of proprioception include parent reports or clinician observation checklists. Direct assessments of proprioceptive function include the Sensory Integration and Praxis Test. Assessing proprioceptive reflexes confirms if proprioceptive afferents are intact.	There are three main testing techniques for assessing proprioception in adults: Threshold to detection of passive motion (TTDPM). Joint position reproduction (JPR) (known as joint position matching). Active movement extent discrimination assessment (AMEDA).	Ageing is associated with a decline in proprioceptive function. Proprioception is required for optimal function during movement and to maintain balance. A decline in proprioception due to ageing affects mobility and increases an individual's risk of falls. Balance deficits can be linked to declines in proprioceptive function during the ageing process.
Vestibular system	"Static balance takes place when the centre of gravity is maintained vertically above the base, without changing the base lengthwise." Static balance develops before the third year of age. Static balance tests include the flamingo test, one-leg stance on a low beam and tandem stance on a force plate. Dynamic balance is defined as the "ability to maintain the centre of gravity above the base during movement, with the body exiting the centre of gravity." Dynamic balance develops between the third and seventh years. Dynamic balance tests include the low-beam walking test.	Vestibular signal impairment is associated with balance disorders and spatial disorientation in neurodegenerative diseases, including Alzheimer's and Parkinson's disease. Balance testing may include: Romberg test: the patient stands on a firm surface with eyes open and closed Balance test progression: standing on a foam-padded surface with eyes closed	20-50% of older adults are diagnosed with a balance impairment. 20-30% of older adults experience one or more falls annually. Ageing is associated with a decline in organ function, and the widespread presence of issues in the balance control systems predisposes older adults to balance impairments. Functional performance tests assess postural activities and movements that occur in the course of everyday life: Romberg test Unipedal stance test (UST), also known as single leg support test and one leg stance test Four-square step test (FSST) Timed up-and-go test Functional reach test (FRT)

Integumentary System

Adequate mobility of the skin and other connective tissues is needed for free movement of the underlying structures to provide postural support and assure proper ventilation. Multiple impairments can be associated with fascial restrictions.

The skin is one of the largest organs of the body. It has many functions, including

• structural barrier
• thermoregulation
• contributes to sensation for neuromuscular control
• provides fascial mobility to allow a joint range of motion

Skin diseases such as atopic dermatitis, psoriasis, and allergic or irritant contact dermatitis affect skin transepidermal water loss (TEWL) (i.e. the amount of water lost through the epidermis from evaporation), hydration, and acidity.

Table 3 provides examples of conditions and changes that can occur in the integumentary system across the lifespan.

Table 3. Integumentary System Across the Lifespan

Children/Adolesents	Adults	Older Adults
The skin barrier function is weaker in children than in adults "Neonatal [skin] barrier functions are in a constant state of flux [...]. It has been proposed that this changing infant skin barrier is not a deficit but beneficial as adaptive flexibility allowing constant optimisation, balancing growth, thermoregulation, water barrier and protective functions". Newborns have the lowest skin hydration and water content. Premature infants have high transepidermal water loss at birth compared to full-term infants because of an immature barrier function and thinner epidermal layers. This causes "increased insensible water loss." Neonatal skin has a higher pH compared to older children and adults. Mature skin pH is maintained between 4.5 to 6.0. Paediatric skin has a tendency to develop xerosis (i.e. excessively dry skin), particularly on the exposed facial skin. This can lead to the development of irritant or allergic contact dermatitis. Scarring from the placement of a gastrostomy tube (G-tube) or chest tube can cause severe restriction in a child's trunk and abdominal mobility.	Extrinsic ageing of the skin is mainly caused by environmental elements such as the sun, air/water pollution, smoking, diet, exercise, stress, lifestyle, repetitive muscle contractions (e.g. frowning, smiling), gravity, or general diseases. Intrinsic ageing of the skin is a natural process resulting from oxidative cellular metabolism. It is influenced by genetics, metabolism, hormonal, immunological, cardiovascular, gastrointestinal, psychogenic, degenerative, or neoplastic disease. In women, the skin thickens at 25 to 30 years of age. A progressive decline follows this in all skin layers as age increases. Androgens, cortisol, progesterone and thyroid hormone influence skin health. For example, thyroid hormone "regulates the metabolic rate of the body and helps regulate epidermal cell proliferation, differentiation, hair and nail growth, wound healing, and skin hydration by affecting the function of dermal fibroblasts".	Skin is thinner and less elastic. Age spots / liver spots tend to develop. Blood vessels under the skin become more fragile, causing bruising or bleeding under the skin. Oil production is decreased, leading to dry, itchy skin. There is a decrease in subcutaneous tissue, which increases the risk of pressure injuries and hypothermia. Sweat function decreases, which increases the risk of overheating. There is an increased risk of skin cancer.

If you would like to learn more about this system, please see: Integumetary System.

Gastrointestinal System

• The gastrointestinal (GI) system occupies the majority of the space in the abdominal compartment
• The following structures surround the abdominal compartment:
  • diaphragm superiorly
  • abdominal wall anteriorly
  • spine posteriorly
  • costal arch on both sides
  • pelvis inferiorly

• The abdominal compartment contains multiple solid and hollow organs, adipose tissue, and major blood vessels. It is located intra- and/ or retro-peritoneally
• The healthy functioning of the GI system depends on the body's ability to generate intra-abdominal pressure

Table 4 provides examples of conditions and changes in the gastrointestinal system that can occur across the lifespan and should be considered in a multiple systems analysis.

Table 4. Gastrointestinal System Across the Lifespan

Children/Adolesents	Adults	Older Adults
Prune belly syndrome (PBS) is associated with laxity of the abdominal wall musculature. Children with PBS often experience gastrointestinal complications due to an inability to generate adequate intra-abdominal pressure. The ability to maintain an appropriate level of intra-abdominal pressure can be impacted in children with cerebral palsy with hypotonic trunk. This can be a factor in the development of digestive issues in children with cerebral palsy, which include upset stomach, vomiting, bloating, and constipation.	Strength training in healthy males, which focuses on increasing the strength of the trunk rotators, "improves the ability to generate higher levels of voluntarily induced intra-abdominal pressure and increases the rate of intra-abdominal pressure development during functional situations."	The strength of oesophagal contractions and tension in the upper oesophagal sphincter decrease. The capacity of the stomach lining to resist damage decreases, which may lead to peptic ulcer disease. Stomach elasticity decreases. A general reduction in physical activity, exercise and pelvic floor weakness may become factors in constipation or faecal incontinence.

Cardiopulmonary System

The following functions of the cardiopulmonary system should be considered in a multiple systems analysis:

• breathing mechanics and patterns
• sleep quality
• oxygen saturation and blood pressure

Table 3. Cardiopulmonary System Across the Lifespan

	Children/Adolescents	Adults	Older Adults
Breathing mechanics and patterns	An infant's respiratory system is less efficient than an adult's Infants aged 12 months and younger are more dependent on diaphragmatic breathing. The main role of the intercostal muscles is chest stabilisation during inspiration. An infant's ribs are positioned more horizontally than an adult's. The ribs move up with inspiration. The absence of up-and-out rib movement limits an infant's capacity to increase tidal volumes. Severe spinal muscle atrophy leads to paradoxical breathing.	The position of the trunk influences chest wall kinematics and breathing patterns. When trunk flexion increases, rib cage displacement and tidal volume are progressively reduced. Athletes may demonstrate dysfunctional breathing patterns. Assessing their breathing pattern may help identify dysfunctional breathing patterns. Incorporating breathing exercises into an athlete's training can help develop an ideal breathing pattern, leading to better exercise performance.	There is a loss of elasticity and a decline in chest wall compliance. Increased rigidity of the chest wall can develop due to osteoporosis and postural changes. There is increasing weakness of the intercostal muscles and accessory muscles of respiration. A functional assessment may include the following observations: ability to speak sentences of different lengths without shortness of breath. ability to sing a song. ability to carry on a conversation during activities.
Sleep quality	Sleep duration, continuity, quality, and daytime sleepiness are associated with cardiovascular risk factors in young people. General standards for optimal sleep should consider an individual's “needs” based on their diet, activity pattern, environment, and genetic makeup. "Short sleep duration and poor sleep quality in children have been associated with concentration, problem behaviour, and emotional instability." A shorter sleep duration of less than 5 hours has been associated with either an increased risk of hypertension or actual hypertension. Recommended hours of sleep to support optimal health are as follows: infants: 12 to 16 hours children between 1-2 years old: 11 to 14 hours Children 3-5 years old: 10–13 hours Children 6-12 years old: 9-12 hours Teenagers 13-18 years old: 8-10 hours	In adults, "short and long duration of sleep are predictors, or markers, of cardiovascular outcomes". The optimal nighttime sleep duration for adults is 7 to 9 hours. Sleep deprivation has been associated with an increased incidence of adverse cardiovascular disorders.	The optimal nighttime sleep duration for older adults is 7 to 9 hours. Sleep quality and its characteristics should be evaluated as healthy sleep patterns are conducive to reducing cardiovascular disease risk.
Oxygen saturation and blood pressure	Up to 9.8% of children and adolescents have systolic hypertension, and up to 7.1% have diastolic hypertension. Blood pressure (BP) at age 13 can predict BP at age 24.	Blood pressure categories in the new American Heart Association guideline: Normal: Less than 120/80 mm Hg. Elevated: Systolic between 120-129 and diastolic less than 80. Hypertensive crisis: Systolic over 180 and/or diastolic over 120, with patients needing changes in medication or immediate hospitalisation. Most adult studies use an SpO2 of less or equal to 95% to define abnormal oxygen saturation.	A respiratory rate at rest (RR) of 28 breaths per minute could be considered the limit between a normal respiratory rate and tachypnoea in older adults. An SpO2 of 91% can be considered the limit of normal in older adults.

Mental Health System

“Without mental health there can be no true physical health” -- Dr Brock Chisholm, the first Director-General of the World Health Organization (WHO)

The World Health Organization defines mental health as comprehensive physical, psychological and social well-being. Economic and social circumstances significantly influence complete mental health, resilience and social support across the lifespan. Older adults often score lower in mental health-related quality of life (MHRQoL) scores. Kang et al. also found that older adults report the highest stress and depression. Stress, depression, and subjective health status influence mental health-related quality of life in adolescents and adults.

The role of physiotherapists in mental health can include:

• promoting health, including mental health
• providing education about mental health
• providing referrals to mental health specialists when necessary
• providing a person-centred approach for children, adolescents, adults, and older adults to enhance physical and emotional well-being through improving posture, respiration and concentration
  • the following low-impact activities may be useful for patients:
    • Yoga (mind-body therapy)
    • Pilates method (balancing of the body and mind)
    • Feldenkrais method (using movement to improve self-awareness and function)
    • Tai-Chi
    • Mindfulness-based therapies
    • Breathing therapies

Resources

• Schenkman M, Butler RB. A model for multisystem evaluation treatment of individuals with Parkinson's disease. Phys Ther. 1989 Nov;69(11):932-43. doi: 10.1093/ptj/69.11.932. PMID: 2813521.
• Massery M, Magee CL. Asthma: multisystem implications. In: Campbell S, Palisano R, Vander Linden D, editors. Physical Therapy for Children. 3 ed. Philadelphia, PA: Elsevier Health Science, 2006. p851-79.